Basic Information
| Provider Information | |||||||||
| NPI: | 1649223447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEESARA | ||||||||
| FirstName: | RAMESH | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 187 W MAIN ST | ||||||||
| Address2: | PO BOX 127 | ||||||||
| City: | DECATURVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318522761 | ||||||||
| FaxNumber: | 7318522781 | ||||||||
| Practice Location | |||||||||
| Address1: | 187 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECATURVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318522761 | ||||||||
| FaxNumber: | 7318522781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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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 | 207R00000X | 12891 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3183218 | 05 | TN | MEDICAID | 0001364 | 01 | TN | BCBS OF TN PIN | OTHER |