Provider Demographics
NPI:1457452583
Name:HUGO A TETTAMANTI MD PA
Entity Type:Organization
Organization Name:HUGO A TETTAMANTI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:A
Authorized Official - Last Name:TETTAMANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-760-4846
Mailing Address - Street 1:2928 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4021
Mailing Address - Country:US
Mailing Address - Phone:336-760-4846
Mailing Address - Fax:336-760-6462
Practice Address - Street 1:2928 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4021
Practice Address - Country:US
Practice Address - Phone:336-760-4846
Practice Address - Fax:336-760-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18235207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011VJMedicaid
NCDE8018OtherRAILROAD MEDICARE
NC011VJOtherBCBSNC
NCDE8018OtherRAILROAD MEDICARE