Basic Information
| Provider Information | |||||||||
| NPI: | 1316997406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANTAMNENI | ||||||||
| FirstName: | VIJAY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | DEAN & ST. MARY'S OUTPATIENT CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | DEAN & ST. MARY'S OUTPATIENT CENTER | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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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 | 208G00000X | 28003-020 | WI | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 3564 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 31497100 | 05 | WI | MEDICAID | 770000422 | 01 | WI | RAILROAD MEDICARE | OTHER |