Healthcare Provider Details

I. General information

NPI: 1063524676
Provider Name (Legal Business Name): NIMMI RAJAGOPAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 W CHICAGO AVE
CHICAGO IL
60651-3226
US

IV. Provider business mailing address

1950 W POLK ST STE 7808
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 773-826-9600
  • Fax:
Mailing address:
  • Phone: 312-413-8170
  • Fax: 312-864-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036112419
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: