Basic Information
Provider Information
NPI: 1003299223
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MADALA
FirstName: SEETHARAMPRASAD
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2100 STANTONSBURG RD
Address2:  
City: GREENVILLE
State: NC
PostalCode: 278342818
CountryCode: US
TelephoneNumber: 2528474810
FaxNumber:  
Practice Location
Address1: 500 ACADEMY ST S
Address2:  
City: AHOSKIE
State: NC
PostalCode: 279103248
CountryCode: US
TelephoneNumber: 2522093000
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/07/2015
LastUpdateDate: 12/30/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/30/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X5315069847MIY Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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