Provider Demographics
NPI:1073530069
Name:MANDEEP S KOHLI DO SC
Entity Type:Organization
Organization Name:MANDEEP S KOHLI DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOHLI
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELORS
Authorized Official - Phone:630-893-0347
Mailing Address - Street 1:360 DONNA LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-8800
Mailing Address - Country:US
Mailing Address - Phone:630-893-0347
Mailing Address - Fax:630-893-1467
Practice Address - Street 1:303 E ARMY TRAIL RD
Practice Address - Street 2:STE# 131
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2169
Practice Address - Country:US
Practice Address - Phone:630-893-0347
Practice Address - Fax:630-893-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232051OtherBCBS
IL208828Medicare PIN
ILH34276Medicare UPIN