Provider Demographics
NPI:1558686964
Name:NIMMAGADDA, ANITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANITHA
Middle Name:
Last Name:NIMMAGADDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 S WOLCOTT AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-413-0369
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4038
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123612207T00000X
IL036-1236122083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400114763Medicare PIN
ILF400116071Medicare PIN