1427095736 NPI number — RENUKA KANDULA M.D.

Table of content: RENUKA KANDULA M.D. (NPI 1427095736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427095736 NPI number — RENUKA KANDULA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANDULA
Provider First Name:
RENUKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427095736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-446-5131
Provider Business Mailing Address Fax Number:
740-446-5486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 JACKSON PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLIPOLIS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45631-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-446-5131
Provider Business Practice Location Address Fax Number:
740-446-5486
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  20268 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 35.074211 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000006517 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001714104 . This is a "MOUNTAIN STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110166885 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000181874 . This is a "UNISON MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2061512 . This is a "OH MEDICAID MOLINA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0081952000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2061512 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 310917085106 . This is a "CARESOURCE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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