=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083637771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VISHWANATH AGRAWAL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 04/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 W HARRISON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-4063
-----------------------------------------------------
Fax | 312-864-9943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 752 CENTURY FARM LN
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-2586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-548-2748
-----------------------------------------------------
Fax | 312-964-9943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 036-085966
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 036-085966
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------