Basic Information
| Provider Information | |||||||||
| NPI: | 1477782522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHALASANI | ||||||||
| FirstName: | PRATIMA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836941 | ||||||||
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| Practice Location | |||||||||
| Address1: | 509 W UNIVERSITY AVE | ||||||||
| Address2: | MILLS CANCER CENTER | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618011645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836636 | ||||||||
| FaxNumber: | 2173833466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-130709 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 036130709 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 036130709 | 05 | IL | MEDICAID |