Provider Demographics
NPI:1659685329
Name:VITTAL V CHAPA MD SC
Entity Type:Organization
Organization Name:VITTAL V CHAPA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VITTAL
Authorized Official - Middle Name:VENKATA
Authorized Official - Last Name:CHAPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-965-5481
Mailing Address - Street 1:138 E DEAN ST
Mailing Address - Street 2:
Mailing Address - City:VIRDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62690-1446
Mailing Address - Country:US
Mailing Address - Phone:217-965-5481
Mailing Address - Fax:217-965-5640
Practice Address - Street 1:138 E DEAN ST
Practice Address - Street 2:
Practice Address - City:VIRDEN
Practice Address - State:IL
Practice Address - Zip Code:62690-1446
Practice Address - Country:US
Practice Address - Phone:217-965-5481
Practice Address - Fax:217-965-5640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052159261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL218072Medicare PIN
ILC37736Medicare UPIN
ILDQ7247Medicare Oscar/Certification