Bhadra Dev Komarraju, APRN AGNP-C
Individual provider Active NPI Gerontology Nurse Practitioner · Hillside, IL
NPI 1831529296 · NPPES record last updated Mar 28, 2018
Key facts
- NPI
- 1831529296
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Gerontology Nurse Practitioner 363LG0600X
- License
- 209010785 (IL)
- Practice address
- 4415 Harrison St
Hillside, IL 60162-1910 - Phone
- (312) 738-3355
- NPI assigned
- Nov 22, 2013
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 9
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in IL, TX, MO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160406002005 | IL | Practitioner - Nurse Practitioner | 1759606296 | Reassigns benefits to 1 organization |
| I20190628000645 | TX | Practitioner - Nurse Practitioner | 1759606296 |
Reassigns benefits to 3 organizations Practice locations: Richmond, TX |
| I20231118000371 | MO | Practitioner - Nurse Practitioner | 1759606296 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 209010785 | IL | MD | Gerontology Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Vpa of Texas PLLC | Current |
Accepting new patients | |
| Signify Health Medical Associates, PLLC | Current |
Accepting new patients | |
| Home Visiting Doctors Management LLC | Current |
Accepting new patients | |
| Vpa PC | Current |
Accepting new patients | |
| Vpa of Texas PLLC | Current |
Accepting new patients | |
| Infinite Medical PC | Current |
Accepting new patients | |
| Vpa PC | Current |
Accepting new patients | |
| Vpa PC | Past | Accepting new patients |
Locations
3430 McKelvey Rd
Ste J
Bridgeton, MO 63044
Phone (314) 551-2101
8706 Manchester Rd
Ste 106
Saint Louis, MO 63144
Phone (314) 961-3570
250 Skillman St
Ste 204
Brooklyn, NY 11205
Phone (513) 341-7173
250 Skillman St
Ste 202
Brooklyn, NY 11205
4055 Valley View Ln
Ste 400
Dallas, TX 75244
Phone (469) 466-7037
5050 Quorum Dr
Ste 700
Dallas, TX 75254
Phone (214) 402-0101
4545 Fuller Dr
Ste 325
Irving, TX 75038
Phone (972) 870-5511
Interoperability endpoints
- bhadra.komarraju@cinq-nyipa.medentdirect.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gerontology Nurse Practitioner | 363LG0600X | 209010785 | IL | Yes |
| Adult Health Nurse Practitioner | 363LA2200X | 209010785 | IL |
Addresses
Primary practice location
4415 Harrison St
Hillside, IL 60162-1910
Mailing address
PO Box 45
Madison, IL 62060-0045
Other providers in Hillside, IL
- Ingalls Provider Group
- Karen'S Home Care Agency
- Rubiya Khan
- Rosemary Ha Eun Kim
- Michael Kochanski
- Jeffrey Wayne Krueger
- Anna Kuczaj
- Gerry Lagua
- Sharon L Lapinski
- Regina L. Lees
All providers in Hillside, IL · Gerontology Nurse Practitioner in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 28, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.