Basic Information
| Provider Information | |||||||||
| NPI: | 1548356678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANNE | ||||||||
| FirstName: | MALLIKARJUNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3133 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063133 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2233 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606223043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 036044990 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZH0000X | 036044990 | IL | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | 036044990 | IL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 01634127 | 01 | IL | BCBS IL | OTHER | 036044990 | 05 | IL | MEDICAID |