Basic Information
| Provider Information | |||||||||
| NPI: | 1770848640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANIPISETTI | ||||||||
| FirstName: | VENU MADHAV | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602023328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473164000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2012 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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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 | 207R00000X | 125061149 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.125961 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD2018-0147 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.