1396908455 NPI number — DR. PRAVEEN NALLAPAREDDY M.D.

Table of content: DR. PRAVEEN NALLAPAREDDY M.D. (NPI 1396908455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396908455 NPI number — DR. PRAVEEN NALLAPAREDDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NALLAPAREDDY
Provider First Name:
PRAVEEN
Provider Middle Name:
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:
1396908455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 SUPERIOR AVE
Provider Second Line Business Mailing Address:
STE G
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-922-3040
Provider Business Mailing Address Fax Number:
219-922-3048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 FIR ST UNIT 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHICAGO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46312-8410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-6002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2008

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: 207RG0100X , with the licence number:  036.118276 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 01072083A , 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: 105715 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 036118276 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 628340 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100202290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 221956 . This is a "IL MEDICAID PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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