Provider Demographics
NPI:1649257593
Name:UNDEVIA, NIDHI (MD)
Entity type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:UNDEVIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:101-1740 LOYOLA UNIVERSITY MEDICAL CENTER
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-5402
Mailing Address - Fax:708-216-6839
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:101-1740 LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:708-216-6839
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL36102139207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36102139Medicaid
I16579Medicare UPIN
ILK09824Medicare ID - Type Unspecified
ILK09823Medicare ID - Type Unspecified