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General NPI Number Information
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NPI Number | 1689734881
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Entity Type | Organization
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Legal Business Name | PRASAD GOURINENI M.D.S.C.
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 07/02/2014
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Provider Practice Location Address
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Address Line | 4440 W.95TH STREET PEDIATRIC AMBULATORY CLINIC
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City | OAK LAWN
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State | IL
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Zip | 60453
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Country | US
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Telephone | 708-684-4563
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Fax | 707-684-4763
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Provider Business Mailing Address
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Address Line | 3420 ADAMS ROAD
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City | OAK BROOK
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State | IL
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Zip | 60523
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Country | US
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Telephone | 630-789-9223
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Fax | 630-242-8307
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PRASAD GOURINENI
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Credential | M.D.
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Telephone | 630-789-9223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036-092558
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License Number State | IL
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