Organization
GORANTLA GOVINDAIAH, M.D., S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GORANTLA GOVINDAIAH MD (OWNER)
(309) 796-1510
Entity
Organization
Contact information
Practice address
4366 KENNEDY DR, SUITE B, EAST MOLINE, IL 61244-4288
(309) 796-1510
(309) 796-1565
Mailing address
4366 KENNEDY DR, SUITE B, EAST MOLINE, IL 61244-4288
(309) 796-1510
(309) 796-1565
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
010063712
RR MEDICARE
—
05
—
036049003
—
IL
01
—
263500
MEDICARE GROUP
IL
01
—
8100279
BCBS
IL
01
—
98669
WELLMARK BCBS
IA
01
—
K44585
MEDICARE INDIVIDUAL
IL
Enumeration date
05/10/2007
Last updated
05/15/2008
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