Healthcare Provider Details

I. General information

NPI: 1801101209
Provider Name (Legal Business Name): ARAVIND ATHIVIRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC3079
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

5841 S MARYLAND AVE # MC3079
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-3531
  • Fax:
Mailing address:
  • Phone: 773-834-3531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.137441
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberP3283
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: