Provider Demographics
NPI:1083655336
Name:JESSE BROWN VA MEDICAL CENTER
Entity Type:Organization
Organization Name:JESSE BROWN VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUBHADRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VUNDAVILLI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:312-569-6397
Mailing Address - Street 1:476 ALLES ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-7871
Mailing Address - Country:US
Mailing Address - Phone:708-539-8119
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-569-6397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL161639OtherNPI ENUMERATOR NUMBER