Healthcare Provider Details

I. General information

NPI: 1275577512
Provider Name (Legal Business Name): RAMESH KOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W PLEASANT AVE
SANDWICH IL
60548-1050
US

IV. Provider business mailing address

15 W PLEASANT AVE
SANDWICH IL
60548-1050
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-9197
  • Fax: 815-786-9199
Mailing address:
  • Phone: 815-786-9197
  • Fax: 815-786-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036074269
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: