Provider Demographics
NPI:1184641847
Name:KUNCHAPPA, KARTHYAYANI (PT)
Entity Type:Individual
Prefix:
First Name:KARTHYAYANI
Middle Name:
Last Name:KUNCHAPPA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1916
Mailing Address - Fax:630-928-5016
Practice Address - Street 1:2973 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9060
Practice Address - Country:US
Practice Address - Phone:517-435-3461
Practice Address - Fax:517-768-9951
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MIKK007396208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C807050OtherBLUE CROSS
MI650C807050OtherBLUE CROSS