| NPI | 1225300833 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GNANESWARA V MIDATHALA Physician/Member 309-310-4399 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology Psychiatry (Licence: FL ME109325) |
| Enumeration Date | 2012-01-30 |
| Last Update Date | 2012-01-30 |