Provider Demographics
NPI:1215923065
Name:KARAMCHANDANI, KISHORE M (MD)
Entity type:Individual
Prefix:
First Name:KISHORE
Middle Name:M
Last Name:KARAMCHANDANI
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 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-661-2368
Mailing Address - Fax:309-662-9709
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-661-2368
Practice Address - Fax:309-662-9709
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093871207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
833120OtherMEDICARE GROUP #
IL036093871Medicaid
ILL64193Medicare PIN
G88568Medicare UPIN
833120OtherMEDICARE GROUP #