Healthcare Provider Details

I. General information

NPI: 1275525495
Provider Name (Legal Business Name): BHARATI CHITTINENI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E BOUGHTON RD SUITE 170
BOLINGBROOK IL
60440-2100
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 262-898-4400
  • Fax: 630-739-3377
Mailing address:
  • Phone: 866-630-9882
  • Fax: 920-682-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-105923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: