Provider Demographics
NPI:1578737631
Name:SHYAM M PUPPALA MDSC
Entity Type:Organization
Organization Name:SHYAM M PUPPALA MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PUPPALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-989-9868
Mailing Address - Street 1:8 RED HILL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-6188
Mailing Address - Country:US
Mailing Address - Phone:773-989-9868
Mailing Address - Fax:773-989-9824
Practice Address - Street 1:4755 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5015
Practice Address - Country:US
Practice Address - Phone:773-989-9868
Practice Address - Fax:773-989-9824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360732812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073281Medicaid
IL036073281Medicaid
ILE18641Medicare UPIN