Healthcare Provider Details

I. General information

NPI: 1417033267
Provider Name (Legal Business Name): BHASKER RAO KOPPULA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

IV. Provider business mailing address

DEPARTMENT OF RADIOLOGY UNIVERSITY OF UTAH 30 NORTH 1900 EAST, #1A071
SALT LAKE CITY UT
84132-2140
US

V. Phone/Fax

Practice location:
  • Phone: 815-334-5566
  • Fax: 815-759-4008
Mailing address:
  • Phone: 801-581-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number7682213-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036166661
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60120325
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7682213-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: