Basic Information
| Provider Information | |||||||||
| NPI: | 1033260476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BICKNELL | ||||||||
| FirstName: | KALPANA | ||||||||
| MiddleName: | PUPPALA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PUPPALA | ||||||||
| OtherFirstName: | KALPANA | ||||||||
| OtherMiddleName: | RAO | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3880 SALEM LAKE DR | ||||||||
| Address2: | STE F | ||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477192220 | ||||||||
| FaxNumber: | 8477192265 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 S. MILWAUKEE AVE. | ||||||||
| Address2: | ADVOCATE CONDELL MEDICAL CENTER | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479905260 | ||||||||
| FaxNumber: | 8473628031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2007 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036.117072 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036117072 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | FP0108274 | 01 | IL | DEA | OTHER |