Healthcare Provider Details

I. General information

NPI: 1972048429
Provider Name (Legal Business Name): BHANU P SANKINENI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 10/29/2022
Certification Date: 10/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 N SHERMAN RD
EDGERTON WI
53534-9002
US

IV. Provider business mailing address

PO BOX 4071
BARRINGTON IL
60011-4071
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number64184-20
License Number StateWI

VIII. Authorized Official

Name: BHANU P SANKINENI
Title or Position: SOLE OWNER
Credential: MD
Phone: 608-561-6644