Basic Information
| Provider Information | |||||||||
| NPI: | 1689670531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONERU | ||||||||
| FirstName: | BHAVANI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912200 | ||||||||
| FaxNumber: | 4194793298 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912200 | ||||||||
| FaxNumber: | 4194793298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35071506 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 341881137 | 01 | OH | FRONT PATH | OTHER | 141978 | 01 | OH | PRIORITY | OTHER | 1689670531 | 05 | MI | MEDICAID | 7779163 | 01 | OH | AETNA | OTHER | 1689670531 | 01 | OH | CIGNA | OTHER | 07603 | 01 | OH | PARAMOUNT | OTHER | 12802 | 01 | MI | HEALTH PLAN OF MICHIGAN | OTHER | 2196903 | 05 | OH | MEDICAID |