1174503205 NPI number — DR. SAIRAMACHANDRA RAO KOLLA M.D

Table of content: DR. SAIRAMACHANDRA RAO KOLLA M.D (NPI 1174503205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174503205 NPI number — DR. SAIRAMACHANDRA RAO KOLLA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLLA
Provider First Name:
SAIRAMACHANDRA
Provider Middle Name:
RAO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1174503205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2757 JOHN F KENNEDY BLVD 1ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07306-5507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-333-8004
Provider Business Mailing Address Fax Number:
201-333-8425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2757 KENNEDY BLVD
Provider Second Line Business Practice Location Address:
1ST FL
Provider Business Practice Location Address City Name:
JERSHEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07306-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-333-8004
Provider Business Practice Location Address Fax Number:
201-333-8425
Provider Enumeration Date:
01/17/2006

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: 208100000X , with the licence number:  234221 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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