Provider Demographics
NPI:1336319094
Name:VYDYANATHAN, AMARESH (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:AMARESH
Middle Name:
Last Name:VYDYANATHAN
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7107
Mailing Address - Country:US
Mailing Address - Phone:309-662-4321
Mailing Address - Fax:309-661-4532
Practice Address - Street 1:1015 S MERCER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7107
Practice Address - Country:US
Practice Address - Phone:309-662-4321
Practice Address - Fax:309-661-4532
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-08
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.009044207L00000X
IL036124700207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124700Medicaid
IL206158002Medicare PIN