Provider Demographics
NPI:1093761504
Name:KANUMURI MEDICAL GROUP PA
Entity Type:Organization
Organization Name:KANUMURI MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NAGESWARARO
Authorized Official - Middle Name:V
Authorized Official - Last Name:KANUMURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-402-0064
Mailing Address - Street 1:PO BOX 2327
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-2327
Mailing Address - Country:US
Mailing Address - Phone:863-402-0064
Mailing Address - Fax:866-746-1525
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:863-402-0064
Practice Address - Fax:866-746-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6804Medicare PIN
FLK6804Medicare ID - Type UnspecifiedGROUP ID