Provider Demographics
NPI:1649200346
Name:CHITTIVELU, KAMALA S (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMALA
Middle Name:S
Last Name:CHITTIVELU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5510
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:248-662-9844
Practice Address - Street 1:2501 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-9401
Practice Address - Country:US
Practice Address - Phone:309-347-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108302207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00325405OtherMETRAHEALTH RR - N. IL
IL036108302Medicaid
ILK29189Medicare ID - Type UnspecifiedSOUTHERN IL
ILP00325405OtherMETRAHEALTH RR - N. IL