MEDICARE: DR. SHYAM PUPPALA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	036073281	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043390099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHYAM PUPPALA MD

Provider Business Mailing Address
First Line	:	8 RED HILL LN
Second Line	:
City	:	SOUTH BARRINGTON
State	:	IL
Zip	:	60010-6188
Country	:	US
Telephone Number	:	773-989-9868
Fax Number	:	773-989-9824

Provider Business Practice Location Address
First Line	:	4755 N KENMORE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5015
Country	:	US
Telephone Number	:	773-989-9868
Fax Number	:	773-989-9824

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	05/27/2008

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