Healthcare Provider Details

I. General information

NPI: 1124474598
Provider Name (Legal Business Name): JAMUNA REDDY GARISA M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 W HARRISON ST
CHICAGO IL
60612-3737
US

IV. Provider business mailing address

1926 W HARRISON ST
CHICAGO IL
60612-3737
US

V. Phone/Fax

Practice location:
  • Phone: 312-391-3443
  • Fax:
Mailing address:
  • Phone: 312-391-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.066527
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: