Provider Demographics
NPI:1659716884
Name:KOLLI MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KOLLI MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEMCHAND
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-925-6625
Mailing Address - Street 1:1600 E FLORIDA AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-8643
Mailing Address - Country:US
Mailing Address - Phone:951-929-8121
Mailing Address - Fax:951-929-2421
Practice Address - Street 1:1600 E FLORIDA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-8643
Practice Address - Country:US
Practice Address - Phone:951-929-8121
Practice Address - Fax:951-929-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty