Basic Information
| Provider Information | |||||||||
| NPI: | 1205842242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYYAGARI | ||||||||
| FirstName: | LAKSHMANA RAO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107325400 | ||||||||
| FaxNumber: | 8107331624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107325400 | ||||||||
| FaxNumber: | 8107331624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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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 | 174400000X | 036054745 | IL | N | Other Service Providers | Specialist | 207RC0000X | 4301106360 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036054745 | 01 | ID | MEDICAL LICENSE | OTHER | 4301106360 | 01 | MI | STATE MEDICAL LICENSE | OTHER | 690280 | 01 | IL | BCBS GROUP ID# | OTHER | 036054745 | 01 | IL | IPA ID# | OTHER | AR1823841 | 01 | IL | DEA | OTHER | 364025739 | 01 | TAX ID | OTHER |