Basic Information
| Provider Information | |||||||||
| NPI: | 1538168786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLB | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173661237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3101 FIELDS SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618223743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173661237 | ||||||||
| FaxNumber: | 2173667491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036-108279 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0361082791 | 05 | IL | MEDICAID |