Provider Demographics
NPI:1376621359
Name:MEDAVARAM, MEHER BALA (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHER
Middle Name:BALA
Last Name:MEDAVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 W BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1520
Mailing Address - Country:US
Mailing Address - Phone:630-378-1234
Mailing Address - Fax:630-378-1155
Practice Address - Street 1:686 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1520
Practice Address - Country:US
Practice Address - Phone:630-378-1234
Practice Address - Fax:630-378-1155
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
09921620OtherBCBS
IL036072434Medicaid
IL036072434Medicaid
E18154Medicare UPIN