1790158186 NPI number — MRS. SUBY ABY PANICHIKUDIYIL NP

Table of content: MRS. SUBY ABY PANICHIKUDIYIL NP (NPI 1790158186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790158186 NPI number — MRS. SUBY ABY PANICHIKUDIYIL NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANICHIKUDIYIL
Provider First Name:
SUBY
Provider Middle Name:
ABY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1790158186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4131 W LOOMIS RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-325-7246
Provider Business Mailing Address Fax Number:
414-325-3770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 CLEARWATER DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK BROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60523-1931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-607-1000
Provider Business Practice Location Address Fax Number:
630-607-1002
Provider Enumeration Date:
11/06/2015

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: 363LF0000X , with the licence number:  209028978 , 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)





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