Provider Demographics
NPI:1447427414
Name:GUNDUMALLA S GOUD MD INC
Entity Type:Organization
Organization Name:GUNDUMALLA S GOUD MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUNDUMALLA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-350-7444
Mailing Address - Street 1:7529 FREDLE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9406
Mailing Address - Country:US
Mailing Address - Phone:440-350-7444
Mailing Address - Fax:440-350-7440
Practice Address - Street 1:7529 FREDLE DR
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-9406
Practice Address - Country:US
Practice Address - Phone:440-350-7444
Practice Address - Fax:440-350-7440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0468480Medicaid
OH110001483AOtherRR MEDICARE
OHGO0501971Medicare PIN
OH0501791Medicare PIN
OH110001483AOtherRR MEDICARE