Basic Information
| Provider Information | |||||||||
| NPI: | 1750546149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUKREJA | ||||||||
| FirstName: | NIDHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | B-522 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125676691 | ||||||||
| FaxNumber: | 3125676156 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | B-522 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125676691 | ||||||||
| FaxNumber: | 3125676156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036120263 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01621679 | 01 | IL | BCBSIL | OTHER | 036120263 | 01 | IL | IL | OTHER | 036120263 01 | 05 | IL | MEDICAID | 950150 | 01 | IL | MEDICARE GROUP # | OTHER |