Provider Demographics
NPI:1093740425
Name:RAO, KOMMULA CHIRANJEEVI (MD)
Entity Type:Individual
Prefix:
First Name:KOMMULA
Middle Name:CHIRANJEEVI
Last Name:RAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:485 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883
Practice Address - Country:US
Practice Address - Phone:419-447-3130
Practice Address - Fax:419-448-3155
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047542R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000026015OtherBCBS INDIVIDUAL ID
OH341042168011OtherMEDICAL MUTUAL OHIO
OH600113OtherBUCKEYE
OH9122391OtherMEDICARE GROUP
OH0359400Medicaid
OH000000024792OtherBCBS GROUP PIN
OH000000026015OtherANTHEM MEDICAID
OH300133952OtherRR MEDICARE PIN
OHCK3646OtherMEDICARE RR GROUP PIN
OH9122391OtherMEDICARE GROUP
OH600113OtherBUCKEYE