Provider Demographics
NPI:1033260476
Name:BICKNELL, KALPANA PUPPALA (MD)
Entity Type:Individual
Prefix:
First Name:KALPANA
Middle Name:PUPPALA
Last Name:BICKNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KALPANA
Other - Middle Name:RAO
Other - Last Name:PUPPALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3880 SALEM LAKE DR
Mailing Address - Street 2:STE F
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5292
Mailing Address - Country:US
Mailing Address - Phone:847-719-2220
Mailing Address - Fax:847-719-2265
Practice Address - Street 1:801 S. MILWAUKEE AVE.
Practice Address - Street 2:ADVOCATE CONDELL MEDICAL CENTER
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-990-5260
Practice Address - Fax:847-362-8031
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.117072207R00000X
IL036117072208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILFP0108274OtherDEA