Provider Demographics
NPI:1487629283
Name:MADALA, CHANDRAMOULI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRAMOULI
Middle Name:
Last Name:MADALA
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 1:363 FREMONT ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3389
Mailing Address - Country:US
Mailing Address - Phone:269-969-6088
Mailing Address - Fax:269-969-6044
Practice Address - Street 1:363 FREMONT ST
Practice Address - Street 2:SUITE 311
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3389
Practice Address - Country:US
Practice Address - Phone:269-969-6088
Practice Address - Fax:269-969-6044
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICM057455207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICM057455OtherSTATE LICENSE NUMBER
MI103064422Medicaid
MIB62639Medicare UPIN
MI01300763112Medicare ID - Type Unspecified