Provider Demographics
NPI:1831159409
Name:KOLUSU, HANUMANTHA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:HANUMANTHA
Middle Name:RAO
Last Name:KOLUSU
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 1:609 35TH AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6146
Mailing Address - Country:US
Mailing Address - Phone:563-243-2022
Mailing Address - Fax:563-243-4070
Practice Address - Street 1:609 35TH AVE STE 1A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6146
Practice Address - Country:US
Practice Address - Phone:563-243-2022
Practice Address - Fax:563-243-4070
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31016174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1134767Medicaid
IAE18815Medicare UPIN
IA1134767Medicaid