Healthcare Provider Details

I. General information

NPI: 1700572930
Provider Name (Legal Business Name): PALLAVI PRABHU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST STE 3200W
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

778 BOGEY CT
ANN ARBOR MI
48103-8844
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-4020
  • 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: