Provider Demographics
NPI:1063675619
Name:SANKINENI, BHANU PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:BHANU PRASAD
Middle Name:
Last Name:SANKINENI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE A102
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8436
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE A102
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8436
Practice Address - Country:US
Practice Address - Phone:615-338-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129148207R00000X, 208M00000X
WI64184-20207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063675619Medicaid