Healthcare Provider Details

I. General information

NPI: 1003262650
Provider Name (Legal Business Name): SITARAM VENKATA CHIVUKULA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W HARRISON ST SUITE 785
CHICAGO IL
60612-3825
US

IV. Provider business mailing address

1750 W HARRISON ST SUITE 785
CHICAGO IL
60612-3825
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: