Basic Information
| Provider Information | |||||||||
| NPI: | 1841619863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KURUVELLA | ||||||||
| FirstName: | TRINATH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 S STATE ST | ||||||||
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| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610085907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109845640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2014 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036153537 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.