Healthcare Provider Details

I. General information

NPI: 1104489251
Provider Name (Legal Business Name): MICHELLE ANN KURUVILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-1027
  • Fax:
Mailing address:
  • Phone: 847-982-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036161580
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036161580
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036161580
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: