MEDICARE: SIVARAM KOLLENGODE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35.066988	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154373561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIVARAM KOLLENGODE M.D.

Provider Business Mailing Address
First Line	:	1251 CLARK ST
Second Line	:
City	:	CAMBRIDGE
State	:	OH
Zip	:	43725-9612
Country	:	US
Telephone Number	:	740-439-0733
Fax Number	:	740-439-8996

Provider Business Practice Location Address
First Line	:	1210 CLARK ST
Second Line	:
City	:	CAMBRIDGE
State	:	OH
Zip	:	43725-9611
Country	:	US
Telephone Number	:	740-435-2468
Fax Number	:	740-439-7251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	11/27/2023

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