Provider Demographics
NPI:1306177720
Name:BRAHMA R KONDA, MD PC
Entity Type:Organization
Organization Name:BRAHMA R KONDA, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAHMA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KONDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-792-6770
Mailing Address - Street 1:1314 10TH ST
Mailing Address - Street 2:P O BOX 245
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-1892
Mailing Address - Country:US
Mailing Address - Phone:309-792-6770
Mailing Address - Fax:309-792-6772
Practice Address - Street 1:1314 10TH ST
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-1892
Practice Address - Country:US
Practice Address - Phone:309-792-6770
Practice Address - Fax:309-792-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101548261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG55176Medicare UPIN
IL593280Medicare PIN