Provider Demographics
NPI:1952310179
Name:KISHOR AJMERE MD LTD
Entity Type:Organization
Organization Name:KISHOR AJMERE MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KISHOR
Authorized Official - Middle Name:G
Authorized Official - Last Name:AJMERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-6023
Mailing Address - Street 1:2435 GLENWOOD AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5461
Mailing Address - Country:US
Mailing Address - Phone:815-744-6005
Mailing Address - Fax:815-744-6023
Practice Address - Street 1:2435 GLENWOOD AVE
Practice Address - Street 2:STE 110
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5461
Practice Address - Country:US
Practice Address - Phone:815-744-6005
Practice Address - Fax:815-744-6023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9900432OtherBC/BS OF ILLINOIS
IL9900432OtherBC/BS OF ILLINOIS
C38308Medicare UPIN