Basic Information
| Provider Information | |||||||||
| NPI: | 1568415859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANYAM | ||||||||
| FirstName: | VANI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423610 | ||||||||
| FaxNumber: | 8122423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 N 6TH 1/2 ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423610 | ||||||||
| FaxNumber: | 8122423630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 01044408A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 35-07-1650M | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | P01012926 | 01 | IN | RAILROAD MEDICARE | OTHER | 759111 | 05 | OH | MEDICAID | 200063780A | 05 | IN | MEDICAID |