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General NPI Number Information
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NPI Number | 1598319659
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Entity Type | Organization
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Legal Business Name | INDEPENDENT MEDICAL GROUP SC
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Dates
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Enumeration Date | 07/27/2019
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Last Update Date | 09/03/2019
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Provider Practice Location Address
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Address Line | 100 BATSON CT STE 204
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City | NEW LENOX
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State | IL
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Zip | 60451-1571
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Country | US
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Telephone | 815-462-1200
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Fax |
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Provider Business Mailing Address
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Address Line | 11039 VENEZIA DR
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City | FRANKFORT
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State | IL
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Zip | 60423-9044
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Country | US
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Telephone | 773-386-4797
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAJASEKHAR KOLLA
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Credential | MD
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Telephone | 773-386-4797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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