Basic Information
| Provider Information | |||||||||
| NPI: | 1366498339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENNUBHOTLA | ||||||||
| FirstName: | RAMANA | ||||||||
| MiddleName: | VENKATA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 RING RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025593636 | ||||||||
| FaxNumber: | 5027690931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39338 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01051972A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 01051972A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 39338 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 64019722 | 05 | KY | MEDICAID | P00396051 | 01 | KY | RR MEDICARE | OTHER |