Provider Demographics
NPI:1598319659
Name:INDEPENDENT MEDICAL GROUP SC
Entity Type:Organization
Organization Name:INDEPENDENT MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJASEKHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-386-4797
Mailing Address - Street 1:11039 VENEZIA DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9044
Mailing Address - Country:US
Mailing Address - Phone:773-386-4797
Mailing Address - Fax:
Practice Address - Street 1:100 BATSON CT STE 204
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1571
Practice Address - Country:US
Practice Address - Phone:815-462-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-27
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty