Provider Demographics
NPI:1649849050
Name:AMBATI, JEEVANA SREEJA (MD)
Entity type:Individual
Prefix:
First Name:JEEVANA SREEJA
Middle Name:
Last Name:AMBATI
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 1:751 N RUTLEDGE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702
Mailing Address - Country:US
Mailing Address - Phone:217-545-0166
Mailing Address - Fax:217-545-1229
Practice Address - Street 1:751 N RUTLEDGE
Practice Address - Street 2:SUITE 1700
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-0166
Practice Address - Fax:217-545-1229
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351048555207R00000X
390200000X
IL125-084109207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program