=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144634833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VENKATESWARA KUMAR KOLLIPARA M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2014
-----------------------------------------------------
Last Update Date | 05/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ST. ELIZABETH HEALTH CENTER, 1044 BELMONT AVE,
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44501-1790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-402-0421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4852, GREENBRIER DR, GIRARD, YOUNGSTOWN
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-402-0421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 57.025031
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------