Healthcare Provider Details

I. General information

NPI: 1386059756
Provider Name (Legal Business Name): PREETAM R BOLLAMPALLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 17TH ST
COLUMBUS IN
47201-5351
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-5974
  • Fax:
Mailing address:
  • Phone: 123-765-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036146843
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01088716A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01088716A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: