Healthcare Provider Details

I. General information

NPI: 1821248881
Provider Name (Legal Business Name): VENKATESWARA P POOLA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CARPENTER ST 1ST FLOOR
SPRINGFIELD IL
62702
US

IV. Provider business mailing address

PO BOX 19677
SPRINGFIELD IL
62794-9677
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-0952
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-135600
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036-135600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: