1568667863 NPI number — KISHORE REDDY RASAMALLU MD

Table of content: KISHORE REDDY RASAMALLU MD (NPI 1568667863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568667863 NPI number — KISHORE REDDY RASAMALLU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RASAMALLU
Provider First Name:
KISHORE
Provider Middle Name:
REDDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RASAMALLU
Provider Other First Name:
VIJAYA KISHORE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568667863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 BREEDLOVE DR
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30655-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-730-3060
Provider Business Mailing Address Fax Number:
888-730-1925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 ROSALIND REDFERN GROVER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79701-5846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-730-3060
Provider Business Practice Location Address Fax Number:
888-730-1925
Provider Enumeration Date:
06/18/2007

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:  MD432046 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: M9598 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: MD432046 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 077148 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: M9598 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1020162720001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2864090000 . This is a "KEYSTONE IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2864090000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 39170 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1988201 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1747437 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30046047 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".