Provider Demographics
NPI:1861468076
Name:VYAS, RAVISHANKER (MD)
Entity Type:Individual
Prefix:
First Name:RAVISHANKER
Middle Name:
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 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4030
Mailing Address - Country:US
Mailing Address - Phone:815-599-7950
Mailing Address - Fax:
Practice Address - Street 1:1036 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4865
Practice Address - Country:US
Practice Address - Phone:815-599-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064141207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064141Medicaid
ILC47304Medicare UPIN
ILL65402Medicare ID - Type UnspecifiedGROUP 433440
IL036064141Medicaid