Provider Demographics
NPI:1346216215
Name:VYAS, KETAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:C
Last Name:VYAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:GRAYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62844
Mailing Address - Country:US
Mailing Address - Phone:618-375-7101
Mailing Address - Fax:618-375-7183
Practice Address - Street 1:610 N COURT ST
Practice Address - Street 2:
Practice Address - City:GRAYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62844
Practice Address - Country:US
Practice Address - Phone:618-375-7101
Practice Address - Fax:618-375-7183
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091476207R00000X
IN01043808A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009707064OtherBLUE CROSS
110136426OtherRAILROAD MEDICARE
IL036091476Medicaid
282819OtherHEALTHLINK
G49012Medicare UPIN
282819OtherHEALTHLINK
IN257900DDMedicare PIN