Basic Information
| Provider Information | |||||||||
| NPI: | 1336319094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VYDYANATHAN | ||||||||
| FirstName: | AMARESH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617017107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096624321 | ||||||||
| FaxNumber: | 3096614532 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617017107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096624321 | ||||||||
| FaxNumber: | 3096614532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2008 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 57.009044 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036124700 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 036124700 | IL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036124700 | 05 | IL | MEDICAID |