Basic Information
| Provider Information | |||||||||
| NPI: | 1174529440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KODAVATIGANTI | ||||||||
| FirstName: | RAMESH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | THE WANAMAKER BUILDING, 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259300 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Practice Location | |||||||||
| Address1: | 34TH STREET AND CIVIC CENTER BOULEVARD | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901867 | ||||||||
| FaxNumber: | 2155905824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | MD433055 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP3000X | MD433055 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | MD433055 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 119106 | 01 | PA | MEDICARE # | OTHER | G83996 | 01 | PA | UPIN | OTHER | MD433055 | 01 | PA | MEDICAL LICENSE | OTHER |