1932108511 NPI number — RAVI KANAKAMEDALA M.D.

Table of content: RAVI KANAKAMEDALA M.D. (NPI 1932108511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932108511 NPI number — RAVI KANAKAMEDALA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANAKAMEDALA
Provider First Name:
RAVI
Provider Middle Name:
Provider Name Prefix Text:
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:
1932108511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8840 CALUMET AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-2545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-7246
Provider Business Mailing Address Fax Number:
219-836-6454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8840 CALUMET AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-836-7246
Provider Business Practice Location Address Fax Number:
219-836-6454
Provider Enumeration Date:
07/18/2005

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: 208VP0014X , with the licence number:  01035342A , 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: 01035342A . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 050085655 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5841131 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000330862 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01035342A . This is a "LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100259430A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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