Basic Information
| Provider Information | |||||||||
| NPI: | 1790049013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGAVALLI | ||||||||
| FirstName: | ANUP | ||||||||
| MiddleName: | KRISHNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 715868 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191714067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042153063 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5899 BREMO ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042888512 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2012 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MT202570 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | ME136492 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 0101272652 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.