1306057914 NPI number — DR. ANURADHA PAVULURI MD

Table of content: DR. ANURADHA PAVULURI MD (NPI 1306057914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306057914 NPI number — DR. ANURADHA PAVULURI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAVULURI
Provider First Name:
ANURADHA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1306057914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2490 RIVERSIDE DR
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31204-1787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-633-6633
Provider Business Mailing Address Fax Number:
478-633-4295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HEMLOCK ST
Provider Second Line Business Practice Location Address:
MSC 10
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-633-7140
Provider Business Practice Location Address Fax Number:
478-633-4295
Provider Enumeration Date:
05/24/2007

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: 208000000X , with the licence number:  ABO 797 603 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 4301094423 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 070401 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1046519 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200000021987 . This is a "PHP COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1046518 . This is a "MCLAREN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 070401 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 3502900092 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com