Basic Information
| Provider Information | |||||||||
| NPI: | 1306402870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLLURI | ||||||||
| FirstName: | POOJITHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVENUE - MERCY FAMILY PHYSICIAN | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192511859 | ||||||||
| FaxNumber: | 4192514159 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625651838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177744400 | ||||||||
| FaxNumber: | 2177746445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2019 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/13/2020 | ||||||||
| NPIReactivationDate: | 02/08/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036158456 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.