Provider Demographics
NPI:1629063243
Name:RAMAKRISHNA, BHAGAVATULA (MD)
Entity type:Individual
Prefix:
First Name:BHAGAVATULA
Middle Name:
Last Name:RAMAKRISHNA
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 1:12251 S 80TH AVE
Mailing Address - Street 2:SUITE 1630
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:SUITE 1630
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-7874
Practice Address - Fax:708-923-7873
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-050628207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050628Medicaid
ILF400293103OtherMEDICARE PTAN
IL21622441OtherBCBS PROVIDER ID
IL21622441OtherBCBS PROVIDER ID
IL14600OtherADVOCATE HLTH PARTNERS