Provider Demographics
NPI:1598758047
Name:SHIVPURI, ROOP REKHA (MD,)
Entity Type:Individual
Prefix:DR
First Name:ROOP
Middle Name:REKHA
Last Name:SHIVPURI
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 1:2050 LARKIN AVE
Mailing Address - Street 2:#100
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4405
Mailing Address - Country:US
Mailing Address - Phone:847-697-2500
Mailing Address - Fax:847-697-2565
Practice Address - Street 1:2050 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5888
Practice Address - Country:US
Practice Address - Phone:847-697-2500
Practice Address - Fax:847-697-2565
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2007-09-05
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-26
Provider Licenses
StateLicense IDTaxonomies
IL36059029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4500577OtherBLUE CROSS BLUE SHIELD
IL4500577OtherBLUE CROSS BLUE SHIELD