Healthcare Provider Details

I. General information

NPI: 1497303556
Provider Name (Legal Business Name): NILA SURESH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 W ROOSEVELT RD
CHICAGO IL
60608-1264
US

IV. Provider business mailing address

1747 W ROOSEVELT RD
CHICAGO IL
60608-1264
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7723
  • Fax: 312-413-7757
Mailing address:
  • Phone: 312-996-7723
  • Fax: 312-413-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036177214
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036177214
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: