Healthcare Provider Details

I. General information

NPI: 1245307305
Provider Name (Legal Business Name): VASANTHA KUMARAIAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST SUITE 311
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

62647 COLLECTION CENTER DR
CHICAGO IL
60693-0626
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-9710
  • Fax:
Mailing address:
  • Phone: 708-478-4302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036048395
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036048395
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: