Provider Demographics
NPI:1689970360
Name:SRINIVAS C KOTA MD SC
Entity Type:Organization
Organization Name:SRINIVAS C KOTA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-378-9785
Mailing Address - Street 1:1280 WINDHAM PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-1673
Mailing Address - Country:US
Mailing Address - Phone:630-378-9785
Mailing Address - Fax:630-378-9836
Practice Address - Street 1:1280 WINDHAM PKWY
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1673
Practice Address - Country:US
Practice Address - Phone:630-378-9785
Practice Address - Fax:630-378-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095253Medicaid
ILG52541Medicare UPIN