Healthcare Provider Details

I. General information

NPI: 1902809536
Provider Name (Legal Business Name): KIRAN BHASKAR KHANOLKAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 W WASHINGTON ST
PITTSFIELD IL
62363-1350
US

IV. Provider business mailing address

640 W WASHINGTON ST
PITTSFIELD IL
62363-1350
US

V. Phone/Fax

Practice location:
  • Phone: 217-285-2113
  • Fax:
Mailing address:
  • Phone: 217-285-2113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036147967
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33370
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: