Individual
DR. AMARESH VYDYANATHAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD, MS
Contact information
Practice address
1015 S MERCER AVE, BLOOMINGTON, IL 61701-7107
(309) 662-4321
(309) 661-4532
Mailing address
1015 S MERCER AVE, BLOOMINGTON, IL 61701-7107
(309) 662-4321
(309) 661-4532
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
57.009044
OH
207LP2900X
Pain Medicine (Anesthesiology) Physician
036124700
IL
208VP0014X
Interventional Pain Medicine Physician
Primary
036124700
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036124700
—
IL
Enumeration date
03/08/2008
Last updated
09/11/2012
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