1558388579 NPI number — VENKAT RAMANA THADAREDDY M.D

Table of content: VENKAT RAMANA THADAREDDY M.D (NPI 1558388579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558388579 NPI number — VENKAT RAMANA THADAREDDY M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THADAREDDY
Provider First Name:
VENKAT
Provider Middle Name:
RAMANA
Provider Name Prefix Text:
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:
1558388579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6210 E HIGHWAY 290 STE 420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78723-1142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-483-9569
Provider Business Mailing Address Fax Number:
124-066-2165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 EXCHANGE BLVD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUTTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78634-5376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-279-3451
Provider Business Practice Location Address Fax Number:
979-279-5163
Provider Enumeration Date:
07/16/2006

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:  J9384 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131090608 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821185299 . This is a "BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC. - AGENCY NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 67-1974 . This is a "BVCAA, INC. DBA HEARNE CHC - FACILITY MEDICARE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131090609 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2872434-01 . This is a "BVCAA DBA HEARNE CHC MEDICAID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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