Basic Information
| Provider Information | |||||||||
| NPI: | 1154325421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENKATACHALAM | ||||||||
| FirstName: | KUMAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 8895 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197382081 | ||||||||
| FaxNumber: | 2197364658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 01048257A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 110168975 | 01 | IN | RAILROAD MEDICARE | OTHER | 9115389 | 01 | IL | ANTHEM BC/BS | OTHER | 200180870A | 05 | IN | MEDICAID | 000000085025 | 01 | IN | ANTHEM BC/BS | OTHER |