Basic Information
| Provider Information | |||||||||
| NPI: | 1790891745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | R. VEDALA AND ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 OHIO BLVD | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 OHIO BLVD | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 05/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | VEDALA | ||||||||
| AuthorizedOfficialFirstName: | RANGANATH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8122350124 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01027928 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000102940 | 01 | IN | BC/BS GROUP # | OTHER | 200085210 | 05 | IN | MEDICAID |