Basic Information
Provider Information | |||||||||
NPI: | 1578531174 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANN | ||||||||
FirstName: | ANURADHA | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
Address2: | SUITE 303 | ||||||||
City: | COLUMBIA | ||||||||
State: | TN | ||||||||
PostalCode: | 384014659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9313889706 | ||||||||
FaxNumber: | 9314901062 | ||||||||
Practice Location | |||||||||
Address1: | 1114 W 7TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | TN | ||||||||
PostalCode: | 384011810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9313889706 | ||||||||
FaxNumber: | 9314901062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 02/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30398 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3826780 | 05 | TN |   | MEDICAID | 3710089 | 05 | TN |   | MEDICAID |