=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811063761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VISHNU MADIREDDY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 MILWAUKEE AVE
-----------------------------------------------------
City | RIVERWOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-325-5110
-----------------------------------------------------
Fax | 847-325-5114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1105 MILWAUKEE AVE
-----------------------------------------------------
City | RIVERWOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-325-5110
-----------------------------------------------------
Fax | 847-325-5114
-----------------------------------------------------
=====================================================
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 | 036091869
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD61327419
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------