Healthcare Provider Details

I. General information

NPI: 1033470919
Provider Name (Legal Business Name): SHEENA REDDY KODAVALURU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE MACNEAL HOSPITAL
BERWYN IL
60402-3429
US

IV. Provider business mailing address

479 N HARLEM AVE APT # 926
OAK PARK IL
60301-6401
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125060854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: