Basic Information
| Provider Information | |||||||||
| NPI: | 1013099225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIJAY M. HARYANI, MD, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 N WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609013483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159363240 | ||||||||
| FaxNumber: | 8159363243 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 N WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609013483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159363240 | ||||||||
| FaxNumber: | 8159363243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARYANI | ||||||||
| AuthorizedOfficialFirstName: | VIJAY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8159363240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036072339 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 4632011 | 01 | IL | BCBS GROUP | OTHER |