Provider Demographics
NPI:1396169280
Name:INTEGRAMED MEDICAL ILLINOIS, LLC
Entity type:Organization
Organization Name:INTEGRAMED MEDICAL ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDEN AND SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYUVEGULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-689-0411
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-0411
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-689-0411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty