Provider Demographics
NPI:1548656838
Name:NANDYALA, ANISHA (MD)
Entity type:Individual
Prefix:
First Name:ANISHA
Middle Name:
Last Name:NANDYALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1842
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:608-364-5452
Practice Address - Street 1:2320 E 93RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3909
Practice Address - Country:US
Practice Address - Phone:773-967-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-148668207R00000X
390200000X
WI69886-20208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080654Medicaid