Provider Demographics
NPI:1467566745
Name:THALLURI, RANGA R (MD)
Entity Type:Individual
Prefix:MR
First Name:RANGA
Middle Name:R
Last Name:THALLURI
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 1:1218 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-4626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4936
Practice Address - Country:US
Practice Address - Phone:330-596-7650
Practice Address - Fax:330-596-7657
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.062816207R00000X
OH35-0628162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0987106Medicaid
OH000000159904OtherBLUE CROSS
OH298948105-017OtherMEDICAL MUTUAL
OH104678000OtherMAGELLAN
OH000000152660OtherBLUE CROSS
OH4083092Medicare ID - Type Unspecified
OH000000159904OtherBLUE CROSS
OH104678000OtherMAGELLAN