Provider Demographics
NPI:1255448460
Name:USHASRI KOGANTI MDSC
Entity type:Organization
Organization Name:USHASRI KOGANTI MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:USHASRI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-434-2048
Mailing Address - Street 1:1129 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350
Mailing Address - Country:US
Mailing Address - Phone:815-343-2048
Mailing Address - Fax:815-434-2177
Practice Address - Street 1:1129 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350
Practice Address - Country:US
Practice Address - Phone:815-343-2048
Practice Address - Fax:815-434-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-096808Medicaid
IL036-096808Medicaid
598870Medicare ID - Type Unspecified