Healthcare Provider Details

I. General information

NPI: 1164505392
Provider Name (Legal Business Name): SWATHI MOTHKUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-907-3032
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036116812
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number63120
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01062446A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-116812
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036116812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: