Basic Information
Provider Information | |||||||||
NPI: | 1689740326 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHENNURU | ||||||||
FirstName: | SUDHATHI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REDDY | ||||||||
OtherFirstName: | SUDHATHI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 PRESTIGE PL STE 550 | ||||||||
Address2: |   | ||||||||
City: | MIAMISBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 453426115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9377621310 | ||||||||
FaxNumber: | 3752280689 | ||||||||
Practice Location | |||||||||
Address1: | 3700 SOUTHERN BLVD STE 401 | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454291265 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8555002873 | ||||||||
FaxNumber: | 9372813913 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2006 | ||||||||
LastUpdateDate: | 08/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35.082992 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 35184146 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 2500609 | 05 | OH |   | MEDICAID |