Provider Demographics
NPI:1548210677
Name:PAVITHRAN, BINDU (MD)
Entity Type:Individual
Prefix:MRS
First Name:BINDU
Middle Name:
Last Name:PAVITHRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:BINDU
Other - Middle Name:
Other - Last Name:VIJAYACHANDRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:612 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5089
Mailing Address - Country:US
Mailing Address - Phone:815-227-8300
Mailing Address - Fax:815-227-8301
Practice Address - Street 1:612 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5089
Practice Address - Country:US
Practice Address - Phone:815-227-8300
Practice Address - Fax:815-227-8301
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110997207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110997Medicaid
ILP00847277OtherRAILROAD MEDICARE PTAN
IL922820OtherGROUP PTAN
ILP00847277OtherRAILROAD MEDICARE PTAN
IL036110997Medicaid
IL216528007Medicare PIN