Provider Demographics
NPI:1689734881
Name:PRASAD GOURINENI M.D.S.C.
Entity Type:Organization
Organization Name:PRASAD GOURINENI M.D.S.C.
Other - Org Name:PEDIATRIC & YOUNG ADULT ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-789-9223
Mailing Address - Street 1:3420 ADAMS ROAD
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-789-9223
Mailing Address - Fax:630-242-8307
Practice Address - Street 1:4440 W.95TH STREET
Practice Address - Street 2:PEDIATRIC AMBULATORY CLINIC
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-684-4563
Practice Address - Fax:707-684-4763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092558207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-092558Medicaid
214890Medicare PIN