Provider Demographics
NPI:1154473635
Name:GOURINENI, VENU (MD)
Entity Type:Individual
Prefix:DR
First Name:VENU
Middle Name:
Last Name:GOURINENI
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 1:1722 SHAFFER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1633
Mailing Address - Country:US
Mailing Address - Phone:269-381-3963
Mailing Address - Fax:
Practice Address - Street 1:1722 SHAFFER ST STE 1
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1633
Practice Address - Country:US
Practice Address - Phone:269-381-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI#4301094579207R00000X
PAMT187681207R00000X
MI4301094579207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154473635Medicaid
MI20-5485614OtherTAX ID
MIVG094579OtherLICENSE
MI110F336360OtherBCBSM
MI20-5485614OtherTAX ID
MIOP41360Medicare PIN