Provider Demographics
NPI:1871514810
Name:KUNCHITHAPATHAM, SELVAKUMAR (MD)
Entity type:Individual
Prefix:
First Name:SELVAKUMAR
Middle Name:
Last Name:KUNCHITHAPATHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SELVA
Other - Middle Name:
Other - Last Name:KUNCHITHAPATHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:630-789-3422
Mailing Address - Fax:630-789-9093
Practice Address - Street 1:908 N ELM ST STE 404
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3638
Practice Address - Country:US
Practice Address - Phone:630-789-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092123207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4174008OtherMEDICARE-LOCALITY 16
ILIL4177008OtherMEDICARE-LOCALITY 15
IL1912218850OtherNPI GROUP PRACTICE