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General NPI Number Information
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NPI Number | 1821211491
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Entity Type | Organization
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Legal Business Name | PRANA CENTER FOR ASTHMA AND ALLERGY LLC
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 01/20/2009
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Provider Practice Location Address
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Address Line | 6857 KINGERY HIGHWAY
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City | WILLOWBROOK
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State | IL
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Zip | 60527
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Country | US
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Telephone | 630-323-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 6714 FIELDSTONE DR
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City | BURR RIDGE
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State | IL
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Zip | 60527
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SAMYUKTA KOPPULA
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Credential | MD
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Telephone | 630-323-8800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 036078244
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License Number State | IL
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