Provider Demographics
NPI:1821211491
Name:PRANA CENTER FOR ASTHMA AND ALLERGY LLC
Entity Type:Organization
Organization Name:PRANA CENTER FOR ASTHMA AND ALLERGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMYUKTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-323-8800
Mailing Address - Street 1:6714 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6857 KINGERY HIGHWAY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-323-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078244207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDN9872Medicare PIN
IL215014Medicare PIN
ILE58906Medicare UPIN