Provider Demographics
NPI:1477717197
Name:DR. HANUMANTHA R. KOLUSU MD, PC
Entity Type:Organization
Organization Name:DR. HANUMANTHA R. KOLUSU MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANUMANTHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOLUSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-243-2022
Mailing Address - Street 1:609 35TH AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6146
Mailing Address - Country:US
Mailing Address - Phone:563-243-2022
Mailing Address - Fax:563-243-4070
Practice Address - Street 1:609 35TH AVE STE 1A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6146
Practice Address - Country:US
Practice Address - Phone:563-243-2022
Practice Address - Fax:563-243-4070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31016261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE18815Medicare UPIN