Provider Demographics
NPI:1447403936
Name:CHOUDARY V. KAVURI MD, SC
Entity Type:Organization
Organization Name:CHOUDARY V. KAVURI MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUNITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-428-1900
Mailing Address - Street 1:1770 E LAKE SHORE DR STE 208
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3839
Mailing Address - Country:US
Mailing Address - Phone:217-428-1900
Mailing Address - Fax:217-428-0358
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE 208
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-428-1900
Practice Address - Fax:217-428-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360720002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05821917OtherBCBS
IL036072000Medicaid
IL531680Medicare UPIN