Provider Demographics
NPI:1447232418
Name:NANDIHALLI, KALLANAGOUDA (MD)
Entity Type:Individual
Prefix:
First Name:KALLANAGOUDA
Middle Name:
Last Name:NANDIHALLI
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 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:711 S HEALTH PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9387
Practice Address - Country:US
Practice Address - Phone:269-273-8557
Practice Address - Fax:269-279-6461
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3146760 10Medicaid
MI4459984 10Medicaid
MI700G560080OtherBCBS GROUP
MI4459993 10Medicaid
MI4892292 10Medicaid
MI1107500091OtherBCBS PIN
MI4258500 10Medicaid
MI23U015Medicare Oscar/Certification
MI3146760 10Medicaid
MIG56008 082Medicare PIN
MIA77687Medicare UPIN
MI700G560080OtherBCBS GROUP
MI230015Medicare Oscar/Certification
MI238599Medicare Oscar/Certification