Provider Demographics
NPI:1215948146
Name:KOHLI, MANOJ (MD)
Entity type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:KOHLI
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 1:1730 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3809
Mailing Address - Country:US
Mailing Address - Phone:217-329-1000
Mailing Address - Fax:217-329-1055
Practice Address - Street 1:1730 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-329-1000
Practice Address - Fax:217-329-1055
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127290207RR0500X
KY35622207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64-021496Medicaid
KY64-021496Medicaid
KY1906202Medicare PIN