Provider Demographics
NPI:1952331993
Name:PADMANABHAN, PASUPATHY (MD)
Entity Type:Individual
Prefix:DR
First Name:PASUPATHY
Middle Name:
Last Name:PADMANABHAN
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:PO BOX 9382
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9382
Mailing Address - Country:US
Mailing Address - Phone:309-691-4410
Mailing Address - Fax:309-589-2830
Practice Address - Street 1:3375 N SEMINARY STREET
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-343-7775
Practice Address - Fax:309-343-2726
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051742207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051742Medicaid
IL036051742Medicaid
ILC98017Medicare UPIN