Basic Information
| Provider Information | |||||||||
| NPI: | 1730133265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOWDA | ||||||||
| FirstName: | KEMPAIAH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15150 FORT ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481951302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342824800 | ||||||||
| FaxNumber: | 7342829302 | ||||||||
| Practice Location | |||||||||
| Address1: | 15150 FORT ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481951302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342824800 | ||||||||
| FaxNumber: | 7342829302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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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 | 207RC0000X | 4301037654 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 4301037652 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 4301037652 | 01 | MI | STATE LICENSE # | OTHER | 1730133265 | 01 | MI | BCBS TYPE 1 NPI # | OTHER | 0608201051 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 11277306 | 01 | MI | CAQH | OTHER | 110007760 | 01 | MI | RR MEDICARE | OTHER | 4301037652 | 01 | MI | CDS # | OTHER | B43075 | 01 | MI | HAP | OTHER | 0820105 | 01 | MI | BLUE CARE NETWORK | OTHER | 1623343 | 05 | MI | MEDICAID |