Basic Information
| Provider Information | |||||||||
| NPI: | 1245307305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUMARAIAH | ||||||||
| FirstName: | VASANTHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62647 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084784302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4400 W 95TH ST | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084249710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036048395 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 036048395 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036048395 | 05 | IL | MEDICAID |