1528089687 NPI number — MRS. GURRAMKONDA NAIDU M.D.

Table of content: MRS. GURRAMKONDA NAIDU M.D. (NPI 1528089687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528089687 NPI number — MRS. GURRAMKONDA NAIDU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAIDU
Provider First Name:
GURRAMKONDA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528089687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 RELIABLE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60682-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-672-4582
Provider Business Mailing Address Fax Number:
309-672-4552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 NE GLEN OAK AVE
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-672-4582
Provider Business Practice Location Address Fax Number:
309-672-4552
Provider Enumeration Date:
07/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036058664 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001011 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0116 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370661223401 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: A61636 . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 115958 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 370661223001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".