Provider Demographics
NPI:1073777843
Name:PURNACHANDRA R YERNENI MD
Entity Type:Organization
Organization Name:PURNACHANDRA R YERNENI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PURNACHANDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:YERNENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-732-9930
Mailing Address - Street 1:1011 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-4334
Mailing Address - Country:US
Mailing Address - Phone:985-732-9930
Mailing Address - Fax:985-732-9884
Practice Address - Street 1:1011 AVENUE F
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-4334
Practice Address - Country:US
Practice Address - Phone:985-732-9930
Practice Address - Fax:985-732-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10096R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5R893Medicare PIN