Healthcare Provider Details

I. General information

NPI: 1881624054
Provider Name (Legal Business Name): AHAMED V.P. KUTTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HERITAGE DR STE 105
BOURBONNAIS IL
60914-1369
US

IV. Provider business mailing address

19 HERITAGE DR STE 105
BOURBONNAIS IL
60914-1369
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-3814
  • Fax: 815-933-3846
Mailing address:
  • Phone: 815-933-3814
  • Fax: 815-933-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0030360527671
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: