1861492480 NPI number — UP RAO MD PA

Table of content: (NPI 1861492480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861492480 NPI number — UP RAO MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UP RAO MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UDIPI PRABHAKAR RAO MD
Provider Other Organization Name Type Code:
4
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:
1861492480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ADAMS AVE
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-4656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-334-0433
Provider Business Mailing Address Fax Number:
432-334-0414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 ADAMS AVE
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-4656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-334-0433
Provider Business Practice Location Address Fax Number:
432-334-0414
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RAO
Authorized Official First Name:
UDIPI
Authorized Official Middle Name:
PRABHAKAR
Authorized Official Title or Position:
PRES. OF THE COMPANY & PHYSICIAN
Authorized Official Telephone Number:
432-334-0433

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  F8631 , 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: 0075PZ . This is a "BLUE CROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1103947 02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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