Basic Information
| Provider Information | |||||||||
| NPI: | 1891751814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NALLU | ||||||||
| FirstName: | RAMCHANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W HIGH ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984573 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 E ELM ST | ||||||||
| Address2: | STE-220 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192295437 | ||||||||
| FaxNumber: | 4192299992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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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 | 208000000X | 35-077589N | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2224140 | 05 | OH | MEDICAID |