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1285623785

NPI Code Detail

MEDICARE: DR. KOUSIKI PATRA MD

MEDICARE: DR. KOUSIKI PATRA 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	208000000X	Pediatrics Physician	35077993	OH
2	2080N0001X	Neonatal-Perinatal Medicine Physician	35077993	OH

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	:	1285623785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOUSIKI PATRA MD

Provider Business Mailing Address
First Line	:	1653 W CONGRESS PKWY
Second Line	:	MURDOCK 622
City	:	CHICAGO
State	:	IL
Zip	:	60612-3833
Country	:	US
Telephone Number	:	312-942-6640
Fax Number	:	312-942-4370

Provider Business Practice Location Address
First Line	:	1653 W CONGRESS PKWY
Second Line	:	MURDOCK 622
City	:	CHICAGO
State	:	IL
Zip	:	60612-3833
Country	:	US
Telephone Number	:	312-942-6640
Fax Number	:	312-942-4370

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	06/13/2011

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Directions to “ DR. KOUSIKI PATRA MD” Practice Location

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