| Organization Name: | GORANTLA GOVINDAIAH, M.D., S.C. |
| NPI Number: | 1023222502 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GORANTLA GOVINDAIAH (OWNER) |
| Mailing Address: | 4366 Kennedy Dr Suite B East Moline |
| State: | IL US |
| Postal Code: | 612444288 |
| Phone Number: | 3097961510 |
| Fax Number: | 3097961565 |
| NPI Enumeration Date: | 05/10/2007 |
| NPI Last Update Date: | 05/15/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QH0100X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Health Service |
| Taxonomy Definition: | |