1639112303 NPI number — DR. KRISHNA C MALINENI M.D.

Table of content: DR. KRISHNA C MALINENI M.D. (NPI 1639112303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639112303 NPI number — DR. KRISHNA C MALINENI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALINENI
Provider First Name:
KRISHNA
Provider Middle Name:
C
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:
1639112303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8075 N SHADELAND AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46250-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-8500
Provider Business Practice Location Address Fax Number:
317-621-8501
Provider Enumeration Date:
06/13/2006

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: 207RC0000X , with the licence number:  01067505A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 036107040 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 01067505A , 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: 1616378 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00427560 . This is a "RRMC-LOCALITY 15" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00798870 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01214659 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1316998578 . This is a "NPI GROUP PRACTICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: K40685 . This is a "MEDICARE PIN-LOCALITY 15" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: K40686 . This is a "MEDICARE PIN-LOCALITY 16" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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