Basic Information
| Provider Information | |||||||||
| NPI: | 1902809536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHANOLKAR | ||||||||
| FirstName: | KIRAN | ||||||||
| MiddleName: | BHASKAR | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623631350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172852113 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 640 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623631350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172852113 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33370 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 036147967 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 421527584003 | 05 | IL | MEDICAID | O278374 | 05 | IA | MEDICAID | 209202605 | 05 | MO | MEDICAID | 33626 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 42152758407 | 01 | JOHN DEERE | OTHER | 421527584 | 01 | TRI-CARE GROUP NUMBER | OTHER |