Provider Demographics
NPI:1629033774
Name:P. DE SILVA, M.D.., S.C.
Entity Type:Organization
Organization Name:P. DE SILVA, M.D.., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, P. DE SILVA, M.D., S.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:PARAKRAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-585-4900
Mailing Address - Street 1:4248 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5037
Mailing Address - Country:US
Mailing Address - Phone:773-585-4900
Mailing Address - Fax:773-585-7262
Practice Address - Street 1:4248 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5037
Practice Address - Country:US
Practice Address - Phone:773-585-4900
Practice Address - Fax:773-585-7262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042344Medicaid
IL21601914OtherBLUE CROSS/ BLUE SHIELD
IL062528037Other(RAILROAD) MEDICARE
ILC41435Medicare UPIN
IL036042344Medicaid