Basic Information
| Provider Information | |||||||||
| NPI: | 1902061195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONERU | ||||||||
| FirstName: | RADHIKA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MUTYALA | ||||||||
| OtherFirstName: | RADHIKA | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 605 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016051901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135844040 | ||||||||
| FaxNumber: | 5084252692 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | ST.JOSEPH HOSPITAL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736653000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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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 | 125050767 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.