Provider Demographics
NPI:1083888093
Name:KANCHANA ESARIYA UMPAI,MD,SC.
Entity Type:Organization
Organization Name:KANCHANA ESARIYA UMPAI,MD,SC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KANCHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESARIYA UMPAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-2556
Mailing Address - Street 1:1026 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2841
Mailing Address - Country:US
Mailing Address - Phone:815-744-2556
Mailing Address - Fax:815-744-3554
Practice Address - Street 1:1026 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2841
Practice Address - Country:US
Practice Address - Phone:815-744-2556
Practice Address - Fax:815-744-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060991Medicaid
IL036060991Medicaid