Basic Information
| Provider Information | |||||||||
| NPI: | 1932246212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONDAMURI | ||||||||
| FirstName: | PADMAJA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEELAVENI | ||||||||
| OtherFirstName: | PADMAJA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8840 CALUMET AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198366422 | ||||||||
| FaxNumber: | 2198367245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01056972A | IN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | P00136513 | 01 | RAILROAD MEDICARE | OTHER | 000000327090 | 01 | IN | IN COMPREHENSIVE INS | OTHER | 000000327090 | 01 | IN | ANTHEM | OTHER | 000000327090 | 01 | IN | BCBS PROVIDER ID | OTHER |