Provider Demographics
NPI:1114290244
Name:VYAS HARSHAVADAN J MD
Entity Type:Organization
Organization Name:VYAS HARSHAVADAN J MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARSHAVADAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-433-3331
Mailing Address - Street 1:1013 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2039
Mailing Address - Country:US
Mailing Address - Phone:815-433-3331
Mailing Address - Fax:815-433-3344
Practice Address - Street 1:1013 CLINTON ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2039
Practice Address - Country:US
Practice Address - Phone:815-433-3331
Practice Address - Fax:815-433-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071120207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071120Medicaid
IL500034350OtherBLUECROSS BLUE SHIELD PROVIDER ID
IL036071120Medicaid
IL910811Medicare PIN