Provider Demographics
NPI:1669476339
Name:ALLA, VENKATESWARARAO (MD)
Entity Type:Individual
Prefix:
First Name:VENKATESWARARAO
Middle Name:
Last Name:ALLA
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 1:400 JOHN DEERE RD
Mailing Address - Street 2:BLDG 1
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6898
Mailing Address - Country:US
Mailing Address - Phone:309-517-3036
Mailing Address - Fax:309-797-1088
Practice Address - Street 1:400 JOHN DEERE RD BLDG 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6898
Practice Address - Country:US
Practice Address - Phone:309-517-3036
Practice Address - Fax:309-797-1088
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056049207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0175471OtherIA PUBLIC AID GP IA POS
IL05232009OtherBLUE CROSS BLUE SHIELD
IA0904573OtherPUBLIC AID
1669476339OtherNPI
IL99236OtherWELLMARK
IL0510917OtherIA PUBLIC AID GROUP IL PO
IA56266OtherWELLMARK
IL036056049Medicaid
IL08100343OtherBLUE CROSS BLUE SHIELD
1740349034OtherGROUP NPI
IL1904573OtherPUBLIC AID IA
IA55646OtherWELLMARK
IL93122OtherWELLMARK
IA55646OtherWELLMARK
K08170Medicare PIN
IL305250Medicare PIN
IL05232009OtherBLUE CROSS BLUE SHIELD
IL209482Medicare PIN
1740349034OtherGROUP NPI
IL93122OtherWELLMARK
ILL61226Medicare PIN