Provider Demographics
NPI:1730199829
Name:PRASAD, PINNAMANENI (MD)
Entity type:Individual
Prefix:
First Name:PINNAMANENI
Middle Name:
Last Name:PRASAD
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-0500
Mailing Address - Country:US
Mailing Address - Phone:217-698-9722
Mailing Address - Fax:217-391-0392
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08421024OtherBC/BS
IL6394POtherCATERPILLAR
IL036049086OtherIL STATE LICENSE
IL110140986OtherRR MEDICARE PIN
IL020057300OtherBLACK LUNG
IL133586700OtherACS-OWCP
IL14D0949277OtherCLIA
IL053701OtherHEALTH ALLIANCE
IL170775OtherPERSONAL CARE
IL036049086Medicaid
IL102120OtherHEALTHLINK
ILCD7143OtherRR MEDICARE GROUP#
IL110140986OtherRR MEDICARE PIN