Provider Demographics
NPI:1558336214
Name:KIZHAKEKUTTU, TINOY (MD)
Entity Type:Individual
Prefix:
First Name:TINOY
Middle Name:
Last Name:KIZHAKEKUTTU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 N HICKORY HILLS RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9418
Mailing Address - Country:US
Mailing Address - Phone:309-453-9581
Mailing Address - Fax:
Practice Address - Street 1:5405 N KNOXVILLE AVE
Practice Address - Street 2:HEARTCARE MIDWEST
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:800-352-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110080207R00000X
IL036-110080207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110080Medicaid
IL07215036OtherBCBS
IL639810Medicare ID - Type UnspecifiedMEDICARE