Provider Demographics
NPI:1699763433
Name:MADALA, RAMAKRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:RAMAKRISHNA
Middle Name:
Last Name:MADALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 EAST CARPENTER ST
Mailing Address - Street 2:ROOM 2K64
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 EAST CARPENTER ST
Practice Address - Street 2:ROOM 2K64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL187256OtherHEALTHLINK UPIN NUMBER
IL085972OtherHEALTH ALLIANCE NUMBER
IL08415040OtherBLUE CROSS BLUE SHIELD
ILL031806OtherCHAMPUS/TRICARE
IL104409OtherHEALTHLINK GROUP NUMBER
IL32490OtherPERSONAL CARE
ILP11998Medicare UPIN
IL1285290Medicare ID - Type UnspecifiedMEDICARE UMWA NUMBER
IL187256OtherHEALTHLINK UPIN NUMBER
ILL031806OtherCHAMPUS/TRICARE
ILCF2131Medicare ID - Type UnspecifiedMEDICARE RR GROUP NUMBER