Provider Demographics
NPI:1780695023
Name:VEERAPANENI, RAGHAVENDRA (MD)
Entity type:Individual
Prefix:DR
First Name:RAGHAVENDRA
Middle Name:
Last Name:VEERAPANENI
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 1:30 E 15TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3459
Mailing Address - Country:US
Mailing Address - Phone:708-754-7777
Mailing Address - Fax:708-754-7811
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:708-754-7777
Practice Address - Fax:708-754-7811
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054308173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054308Medicaid
ILF400195122OtherMEDICARE PTAN
IL0001623866OtherBLUE CROSS BLUE SHIELD
IL080165393OtherMEDICARE RAILROAD
ILC42325Medicare UPIN
ILL82991Medicare ID - Type Unspecified