Provider Demographics
NPI:1013900851
Name:VADALI, MAITRAYEE SUNDARESAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAITRAYEE
Middle Name:SUNDARESAN
Last Name:VADALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE STE 1520
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:708-923-4200
Mailing Address - Fax:708-923-4201
Practice Address - Street 1:12251 S 80TH AVE STE 1520
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:708-923-4200
Practice Address - Fax:708-923-4201
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102767207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102767Medicaid
ILP00157926OtherPALMETTO GBA INDIVIDUAL #
ID21622931OtherBCBS GROUP #
ILCI8250OtherPALMETTO GBA GROUP #
IL036102767Medicaid
IL388180Medicare ID - Type UnspecifiedANOTHER MEDICARE GROUP #
ID21622931OtherBCBS GROUP #
ILK05885Medicare ID - Type UnspecifiedMEDICARE INDIV PROV ID #