1639252265 NPI number — MR. RUDRAPPA GANGADHAR MD

Table of content: MR. RUDRAPPA GANGADHAR MD (NPI 1639252265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639252265 NPI number — MR. RUDRAPPA GANGADHAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANGADHAR
Provider First Name:
RUDRAPPA
Provider Middle Name:
Provider Name Prefix Text:
MR.
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:
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:
1639252265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29417-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-554-9300
Provider Business Mailing Address Fax Number:
843-566-8780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 W. UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNCIE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47303-3428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-747-3134
Provider Business Practice Location Address Fax Number:
765-741-2905
Provider Enumeration Date:
10/24/2006

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: 207ZP0102X , with the licence number:  01027269A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2099554 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0894797 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000033875 . This is a "M-PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 6470 . This is a "PHYSICIAN HEALTH PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000386864 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100077010 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020434700 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".




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