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General NPI Number Information
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NPI Number | 1144552126
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Entity Type | Organization
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Legal Business Name | MADHU GUNDAVARAM MD SC
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Dates
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Enumeration Date | 02/02/2010
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Last Update Date | 02/02/2010
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Provider Practice Location Address
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Address Line | 326 W 64TH ST
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City | CHICAGO
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State | IL
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Zip | 60621-3114
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Country | US
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Telephone | 773-962-3900
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Fax |
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Provider Business Mailing Address
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Address Line | 655 W HOBBIE ST
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City | CHICAGO
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State | IL
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Zip | 60610-2433
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Country | US
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Telephone | 773-354-0210
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MADHU S GUNDAVARAM
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Credential | MD
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Telephone | 773-354-0210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036112955
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License Number State | IL
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