MEDICARE: RACHELINA PORTOLESE KVIETKUS 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	01045522	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01306109	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000000772015	OTHER	IN	BCBS BMG GOSHEN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376586420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHELINA PORTOLESE KVIETKUS M.D.

Provider Business Mailing Address
First Line	:	211 N EDDY ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-3096
Country	:	US
Telephone Number	:	574-237-9340
Fax Number	:	574-239-1474

Provider Business Practice Location Address
First Line	:	211 N EDDY ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-3096
Country	:	US
Telephone Number	:	574-237-9340
Fax Number	:	574-239-1474

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	10/22/2018

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