Basic Information
| Provider Information | |||||||||
| NPI: | 1093740425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | KOMMULA | ||||||||
| MiddleName: | CHIRANJEEVI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1108 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481061108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 485 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194473130 | ||||||||
| FaxNumber: | 4194483155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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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 | 2085R0202X | 35047542R | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000026015 | 01 | OH | BCBS INDIVIDUAL ID | OTHER | 341042168011 | 01 | OH | MEDICAL MUTUAL OHIO | OTHER | 600113 | 01 | OH | BUCKEYE | OTHER | 9122391 | 01 | OH | MEDICARE GROUP | OTHER | 0359400 | 05 | OH | MEDICAID | 000000024792 | 01 | OH | BCBS GROUP PIN | OTHER | 000000026015 | 01 | OH | ANTHEM MEDICAID | OTHER | 300133952 | 01 | OH | RR MEDICARE PIN | OTHER | CK3646 | 01 | OH | MEDICARE RR GROUP PIN | OTHER |