Healthcare Provider Details

I. General information

NPI: 1902062862
Provider Name (Legal Business Name): PRIYA KUMARAGURU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY SUITE 205
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY SUITE 205
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-462-2222
  • Fax: 618-463-5004
Mailing address:
  • Phone: 618-462-2222
  • Fax: 618-462-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036127459
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: