Healthcare Provider Details

I. General information

NPI: 1154325421
Provider Name (Legal Business Name): KUMAR VENKATACHALAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8895 BROADWAY
MERRILLVILLE IN
46410-7037
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-2081
  • Fax: 219-736-4658
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01048257A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: