Basic Information
| Provider Information | |||||||||
| NPI: | 1588636195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANNAVA | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 S WOOD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129966736 | ||||||||
| FaxNumber: | 3129967378 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | HAMLET | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283453100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105823445 | ||||||||
| FaxNumber: | 9105824475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2017 | ||||||||
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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 | 207R00000X | 200501235 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 036.142986 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 183193 | 01 | NC | MEDCOST | OTHER | 5657272 | 01 | NC | FIRST HEALTH | OTHER | 1400X | 01 | NC | BCBS OF NC | OTHER | 7461708 | 01 | NC | AETNA | OTHER |