MEDICARE: DR. SRINIVAS CHAKRAVARTHY KOTA 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	207R00000X	Internal Medicine Physician	036095253	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9932023	OTHER		BCBS

General Provider Information

NPI Number	:	1659481562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SRINIVAS CHAKRAVARTHY KOTA MD

Provider Business Mailing Address
First Line	:	3256 LAPP LN
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8350
Country	:	US
Telephone Number	:	630-378-9785
Fax Number	:	630-378-9836

Provider Business Practice Location Address
First Line	:	726 S WEBER RD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60490-5451
Country	:	US
Telephone Number	:	630-378-9785
Fax Number	:	630-348-9836

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	03/21/2013

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