MEDICARE: BAPUSHETTY MADOORI MD SC

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	261QP2300X	Primary Care Clinic/Center	036057250	IL

General Provider Information

NPI Number	:	1508018326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPUSHETTY MADOORI MD SC

Provider Business Mailing Address
First Line	:	15617 SUNSET RIDGE DR
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-4925
Country	:	US
Telephone Number	:	708-590-9805
Fax Number	:

Provider Business Practice Location Address
First Line	:	6905 S WENTWORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3734
Country	:	US
Telephone Number	:	708-590-9805
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BAPUSHETTY MADOORI
Credential	:	M.D.
Telephone Number	:	708-590-9805

Provider Enumeration Date	:	10/13/2008
Last Update Date	:	10/13/2008

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