Basic Information
| Provider Information | |||||||||
| NPI: | 1265750178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAGRALE | ||||||||
| FirstName: | VIDYA | ||||||||
| MiddleName: | PREMANAND | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | INGOLE | ||||||||
| OtherFirstName: | VIDYA | ||||||||
| OtherMiddleName: | SUDEEP | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 840 S. WOOD ST, SUITE 130CSN DEPT OF PATHOLOGY (MC847) | ||||||||
| Address2: | UNIVERSITY OF ILLINOIS AT CHICAGO | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 W. TAYLOR | ||||||||
| Address2: | UNIVERSITY OF ILLINOIS | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2010 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 125058857 | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.