Basic Information
| Provider Information | |||||||||
| NPI: | 1639252265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGADHAR | ||||||||
| FirstName: | RUDRAPPA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W. UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657473134 | ||||||||
| FaxNumber: | 7657412905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
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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 | 207ZP0102X | 01027269A | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 2099554 | 05 | OH | MEDICAID | 0894797 | 05 | OH | MEDICAID | 000000033875 | 01 | IN | M-PLAN | OTHER | 6470 | 01 | IN | PHYSICIAN HEALTH PLAN | OTHER | 000000386864 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 100077010 | 05 | IN | MEDICAID | 020434700 | 01 | BLACK LUNG | OTHER |