Provider Demographics
NPI:1588840607
Name:INTERNAL MEDICINE CENTER
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVIKIRAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:TAMRAGOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-241-1616
Mailing Address - Street 1:1909 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2602
Mailing Address - Country:US
Mailing Address - Phone:630-241-1616
Mailing Address - Fax:630-541-0066
Practice Address - Street 1:1909 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2602
Practice Address - Country:US
Practice Address - Phone:630-241-1616
Practice Address - Fax:630-541-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073705261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073705Medicaid
IL2215606OtherBLUE CROSS
IL=========OtherUNITED HEALTH CARE
IL=========OtherHUMANA
IL=========OtherCIGNA
IL0=========Medicaid
IL2215606OtherBLUE CROSS
IL2215606OtherBLUE CROSS
IL925290Medicare PIN