Provider Demographics
NPI:1104173533
Name:MIDWEST OBGYN & INFERTILITY CENTER
Entity type:Organization
Organization Name:MIDWEST OBGYN & INFERTILITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDYA
Authorized Official - Middle Name:SAGAR RAO
Authorized Official - Last Name:MORISETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-875-1886
Mailing Address - Street 1:675 E SNYDER DR STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4766
Mailing Address - Country:US
Mailing Address - Phone:217-875-1886
Mailing Address - Fax:217-875-3120
Practice Address - Street 1:675 E SNYDER DR STE 1
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4766
Practice Address - Country:US
Practice Address - Phone:217-875-1886
Practice Address - Fax:217-875-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084779207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty