Provider Demographics
NPI:1245307305
Name:KUMARAIAH, VASANTHA (MD)
Entity type:Individual
Prefix:
First Name:VASANTHA
Middle Name:
Last Name:KUMARAIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62647 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0626
Mailing Address - Country:US
Mailing Address - Phone:708-478-4302
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 311
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-424-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048395207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048395Medicaid
D13250Medicare UPIN
ILF400261801Medicare PIN
IL036048395Medicaid
ILF400261798Medicare PIN