Provider Demographics
NPI:1902809536
Name:KHANOLKAR, KIRAN BHASKAR (MD)
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:BHASKAR
Last Name:KHANOLKAR
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 1:640 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1350
Mailing Address - Country:US
Mailing Address - Phone:217-285-2113
Mailing Address - Fax:
Practice Address - Street 1:640 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1350
Practice Address - Country:US
Practice Address - Phone:217-285-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33370207Q00000X
IL036147967207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
33626OtherBLUE CROSS BLUE SHIELD
IL421527584003Medicaid
IAO278374Medicaid
MO209202605Medicaid
421527584OtherTRI-CARE GROUP NUMBER
42152758407OtherJOHN DEERE
42152758407OtherJOHN DEERE
MO209202605Medicaid
IAI7908Medicare PIN