Provider Demographics
NPI:1508018326
Name:BAPUSHETTY MADOORI MD SC
Entity Type:Organization
Organization Name:BAPUSHETTY MADOORI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAPUSHETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MADOORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-590-9805
Mailing Address - Street 1:15617 SUNSET RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4925
Mailing Address - Country:US
Mailing Address - Phone:708-590-9805
Mailing Address - Fax:
Practice Address - Street 1:6905 S WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3734
Practice Address - Country:US
Practice Address - Phone:708-590-9805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057250261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL628410Medicare PIN
D14061Medicare UPIN
ILD14061Medicare UPIN