Basic Information
| Provider Information | |||||||||
| NPI: | 1407930514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | GAUTAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 W PRATT ST | ||||||||
| Address2: | SUITE 880 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212012423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141302 | ||||||||
| FaxNumber: | 4103283379 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | SUITE S3AX-19 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141302 | ||||||||
| FaxNumber: | 4103283379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
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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 | 207VX0201X | MD39934 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | D72905 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 440080100 | 05 | MD | MEDICAID | 4164064 | 01 | TN | BCBS TN | OTHER |