Provider Demographics
NPI:1649219544
Name:NAGARAJ, ATHIHALLI S (MD)
Entity Type:Individual
Prefix:
First Name:ATHIHALLI
Middle Name:S
Last Name:NAGARAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34404 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1344
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:
Practice Address - Street 1:3435 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-3312
Practice Address - Country:US
Practice Address - Phone:773-265-4571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine