1760739148 NPI number — DR. PRATIBHA RANGANATHA BURLI M.D

Table of content: DR. PRATIBHA RANGANATHA BURLI M.D (NPI 1760739148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760739148 NPI number — DR. PRATIBHA RANGANATHA BURLI M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURLI
Provider First Name:
PRATIBHA
Provider Middle Name:
RANGANATHA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1760739148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 UNIVERSITY BLVD
Provider Second Line Business Mailing Address:
UH2440
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-5149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-948-3026
Provider Business Mailing Address Fax Number:
317-944-7417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
UH2440
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-5149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-948-3026
Provider Business Practice Location Address Fax Number:
317-944-7417
Provider Enumeration Date:
08/05/2012

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: 207V00000X , with the licence number:  01072551A , 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: 201193910 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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