=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053595934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAVANA RADHAKRISHNA M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 09/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 OGDEN AVE.
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-565-8607
-----------------------------------------------------
Fax | 312-563-8661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 OGDEN AVE. STE. P050
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-565-8607
-----------------------------------------------------
Fax | 312-563-8661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036120016
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------