Provider Demographics
NPI:1366498339
Name:CHENNUBHOTLA, RAMANA VENKATA (MD)
Entity Type:Individual
Prefix:
First Name:RAMANA
Middle Name:VENKATA
Last Name:CHENNUBHOTLA
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2410 RING RD STE 500
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7991
Practice Address - Country:US
Practice Address - Phone:502-559-3636
Practice Address - Fax:502-769-0931
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39338207R00000X, 207RE0101X
IN01051972A207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64019722Medicaid
KYP00396051OtherRR MEDICARE
ING99214Medicare UPIN
KY64019722Medicaid