Provider Demographics
NPI:1194990853
Name:NEUROLOGY CLINIC OF DANVILLE, LLC
Entity type:Organization
Organization Name:NEUROLOGY CLINIC OF DANVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VATHIAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAZUDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-431-8400
Mailing Address - Street 1:701 W. FAIRCHILD STREET
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3745
Mailing Address - Country:US
Mailing Address - Phone:217-431-8400
Mailing Address - Fax:217-431-0387
Practice Address - Street 1:701 W FAIRCHILD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3745
Practice Address - Country:US
Practice Address - Phone:217-431-8400
Practice Address - Fax:217-431-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061107174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206062Medicare UPIN