Provider Demographics
NPI:1679672869
Name:TIPIRNENI, NAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:NAVEEN
Middle Name:
Last Name:TIPIRNENI
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 1:1015 S MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7435 W TALCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3707
Practice Address - Country:US
Practice Address - Phone:773-792-5177
Practice Address - Fax:773-792-7926
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227945207L00000X
IL036118887207L00000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118887Medicaid
ILP00411152OtherRAILROAD MEDICARE
IL036118887Medicaid
ILK39372Medicare PIN