Basic Information
| Provider Information | |||||||||
| NPI: | 1477994366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANNEGOLLA | ||||||||
| FirstName: | KARTHIK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126764660 | ||||||||
| FaxNumber: | 8123552751 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126764660 | ||||||||
| FaxNumber: | 8123552751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2013 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301102865 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 01076648A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.