Healthcare Provider Details

I. General information

NPI: 1831273994
Provider Name (Legal Business Name): K RANGA RAMA KRISHNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 600
CHICAGO IL
60612-2847
US

IV. Provider business mailing address

1645 W JACKSON BLVD STE 600
CHICAGO IL
60612-2847
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5372
  • Fax:
Mailing address:
  • Phone: 312-942-5372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-139401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: