Provider Demographics
NPI:1164716056
Name:MADOORI, SATHYAKIRAN B (MD)
Entity Type:Individual
Prefix:
First Name:SATHYAKIRAN
Middle Name:B
Last Name:MADOORI
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 1:2618 W SUGNET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:486 RANDALL RD UNIT B
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-3354
Practice Address - Country:US
Practice Address - Phone:224-783-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098766207P00000X, 207Q00000X
IL036136116207P00000X
IL036-136116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301098766OtherSTATE LICENSE