Healthcare Provider Details

I. General information

NPI: 1376379156
Provider Name (Legal Business Name): DINESH ARAVIND RONGALI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 479
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

600 S PAULINA ST STE 479
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3972
  • Fax:
Mailing address:
  • Phone: 312-942-3972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number125084489
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: