Provider Demographics
NPI:1275526071
Name:AVULA, SURENDRA B (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:B
Last Name:AVULA
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 1:4950 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2504
Mailing Address - Country:US
Mailing Address - Phone:708-576-8150
Mailing Address - Fax:708-576-8831
Practice Address - Street 1:4950 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2504
Practice Address - Country:US
Practice Address - Phone:708-576-8150
Practice Address - Fax:708-576-8831
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082117207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082117Medicaid
IL21622931OtherBCBS GROUP #
IL060053845OtherPALMETTO GBA INDIVIDUAL #
ILCI8250OtherPALMETTO GBA GROUP #
ILCI8250OtherPALMETTO GBA GROUP #
IL526200Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL036082117Medicaid