Basic Information
| Provider Information | |||||||||
| NPI: | 1639126337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YALAMANCHILI | ||||||||
| FirstName: | B | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 182255 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432182255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138522442 | ||||||||
| FaxNumber: | 6144305742 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 LORETTO RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400331300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706925158 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 21936 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000071071 | 01 | ANTHEM | OTHER | 64781651 | 05 | KY | MEDICAID |