Basic Information
| Provider Information | |||||||||
| NPI: | 1699852939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHREENIVAS | ||||||||
| FirstName: | BINDIGANAVLE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | B | ||||||||
| OtherFirstName: | SHREENIVAS | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6084 S ARCHER AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606382747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844152 | ||||||||
| FaxNumber: | 7738844167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036053085 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036053085 | 05 | IL | MEDICAID | 11024172 | 01 | IL | RAIL ROAD MEDICARE | OTHER | 21608591 | 01 | IL | BCBS PROVIDER ID | OTHER |