Provider Demographics
NPI:1225266984
Name:PANDURANGA R KINI MD, LTD
Entity Type:Organization
Organization Name:PANDURANGA R KINI MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PANDURANGA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-1151
Mailing Address - Street 1:7 PARK PLACE
Mailing Address - Street 2:STE A
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2916
Mailing Address - Country:US
Mailing Address - Phone:618-233-1151
Mailing Address - Fax:618-235-1079
Practice Address - Street 1:7 PARK PL STE A
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2916
Practice Address - Country:US
Practice Address - Phone:618-233-1151
Practice Address - Fax:618-235-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360643102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
08200528OtherBCBS
IL130000629OtherRR MEDICARE
IL100708OtherHEALTHLINK
34490OtherGHP
IL4000537OtherAETNA
IL036064310Medicaid