Basic Information
| Provider Information | |||||||||
| NPI: | 1417190216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTHULINGAM | ||||||||
| FirstName: | VARATHASEELAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S 14TH ST | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629483631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422171 | ||||||||
| FaxNumber: | 6183514919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036122038 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | P00757187 | 01 | IL | RAILROAD MEDICARE | OTHER | 976183 | 01 | IL | HEALTHLINK | OTHER | 036122038 | 01 | IL | ILLINOIS LICENSE | OTHER | 036122038 | 05 | IL | MEDICAID | 165651 | 01 | IL | HEALTH ALLIANCE | OTHER |