Basic Information
| Provider Information | |||||||||
| NPI: | 1619106986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANKA | ||||||||
| FirstName: | KIRAN | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 MOYE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278344300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527442335 | ||||||||
| FaxNumber: | 2527443811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2009 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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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 | 2080N0001X | 2014-01750 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 2014-01750 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1619106986 | 05 | NC | MEDICAID | NCQ4130322 | 01 | NC | MEDICARE | OTHER | 1890J | 01 | NC | BCBS OF NC | OTHER |