1417912296 NPI number — DR. DHRUVA R. TILWALLI MD

Table of content: DR. DHRUVA R. TILWALLI MD (NPI 1417912296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417912296 NPI number — DR. DHRUVA R. TILWALLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILWALLI
Provider First Name:
DHRUVA
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1417912296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 W 755 BUTTERFIELD RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
OAKBROOK TERRACE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-827-0100
Provider Business Mailing Address Fax Number:
630-827-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 W 755 BUTTERFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OAKBROOK TERRACE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60181-4253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-827-0100
Provider Business Practice Location Address Fax Number:
630-827-0103
Provider Enumeration Date:
04/17/2006

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: 207RG0100X , with the licence number:  036050661 , 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: 036050661 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036050661/01 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 995271 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 21608842 . This is a "BCBS IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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