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General NPI Number Information
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NPI Number | 1831529296
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Entity Type | Individual
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Provider Name | BHADRA DEV KOMARRAJU APRN AGNP-C
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Gender | Male
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Dates
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Enumeration Date | 11/22/2013
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Last Update Date | 03/28/2018
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Provider Practice Location Address
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Address Line | 4415 HARRISON ST
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City | HILLSIDE
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State | IL
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Zip | 60162-1910
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Country | US
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Telephone | 312-738-3355
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 45
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City | MADISON
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State | IL
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Zip | 62060-0045
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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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209010785
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 209010785
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License Number State | IL
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