Healthcare Provider Details

I. General information

NPI: 1003044280
Provider Name (Legal Business Name): NUPUR MITTAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W. HARRISON ST SUITE 710 RUSH UNIVERSITY MEDICAL CENTER,
CHICAGO IL
60612
US

IV. Provider business mailing address

1620 W. CONGRESS PKWY SUITE 447 PAVILION C/O EMILY SUSSKIND, RUSH UNIVERSITY MEDICAL CENTER,
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5983
  • Fax: 312-563-2519
Mailing address:
  • Phone: 312-942-7098
  • Fax: 312-942-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-131173
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: