Healthcare Provider Details

I. General information

NPI: 1902126030
Provider Name (Legal Business Name): V BHOOPAL MD,SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 S RIDGELAND AVE SUITE E
PALOS HEIGHTS IL
60463-2390
US

IV. Provider business mailing address

12800 S RIDGELAND AVE SUITE E
PALOS HEIGHTS IL
60463-2390
US

V. Phone/Fax

Practice location:
  • Phone: 708-388-4911
  • Fax: 708-388-4933
Mailing address:
  • Phone: 708-388-4911
  • Fax: 708-388-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036056748
License Number StateIL

VIII. Authorized Official

Name: DR. VASIREDDY BHOOPAL
Title or Position: FAMILY PRACTICE
Credential: MD
Phone: 708-388-4911