Basic Information
| Provider Information | |||||||||
| NPI: | 1649423872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNGARA | ||||||||
| FirstName: | CHARAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD, MONUMENT HEALTH RAPID CITY HOSPITAL | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054419459 | ||||||||
| FaxNumber: | 6057550707 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD, MONUMENT HEALTH RAPID CITY HOSPITAL | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054419459 | ||||||||
| FaxNumber: | 6057550707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 11971 | SD | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 201029750 | 05 | IN | MEDICAID | 000000727503 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 1649423872 | 05 | WI | MEDICAID |