Provider Demographics
NPI:1760440580
Name:KRISHNAMOORTHY, SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:KRISHNAMOORTHY
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 1:1054 M L KING DR
Mailing Address - Street 2:SUITE 126
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3000
Mailing Address - Country:US
Mailing Address - Phone:618-533-5500
Mailing Address - Fax:618-533-5501
Practice Address - Street 1:1054 M L KING DR
Practice Address - Street 2:SUITE 126
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3000
Practice Address - Country:US
Practice Address - Phone:618-533-5500
Practice Address - Fax:618-533-5501
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091773207RG0300X
IL207RE0101X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-091773Medicaid
IL209743Medicare ID - Type Unspecified
IL036-091773Medicaid