Provider Demographics
NPI:1982697785
Name:GOURINENI, PRASAD (MD)
Entity type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:
Last Name:GOURINENI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1971
Mailing Address - Country:US
Mailing Address - Phone:708-237-7200
Mailing Address - Fax:708-237-7201
Practice Address - Street 1:10330 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1971
Practice Address - Country:US
Practice Address - Phone:708-237-7200
Practice Address - Fax:708-237-7201
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092558207XP3100X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-092558-5Medicaid
IL036-092558-5Medicaid
ILK17383/357801Medicare ID - Type Unspecified