MEDICARE: DR. PRASANNA C KUMAR 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	207R00000X	Internal Medicine Physician		IL
2	207RC0000X	Cardiovascular Disease Physician		IL

General Provider Information

NPI Number	:	1285639559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRASANNA C KUMAR M.D.

Provider Business Mailing Address
First Line	:	3165 MYRTLE AVE
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5012
Country	:	US
Telephone Number	:	618-877-3066
Fax Number	:	618-877-3060

Provider Business Practice Location Address
First Line	:	3165 MYRTLE AVE
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5012
Country	:	US
Telephone Number	:	618-877-3066
Fax Number	:	618-877-3060

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	01/28/2008

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