Provider Demographics
NPI:1497754287
Name:KONDAMURI, SHANU (MD)
Entity Type:Individual
Prefix:
First Name:SHANU
Middle Name:
Last Name:KONDAMURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHAUN
Other - Middle Name:
Other - Last Name:KONDAMURI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8840 CALUMET AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2545
Mailing Address - Country:US
Mailing Address - Phone:219-836-7246
Mailing Address - Fax:219-836-6454
Practice Address - Street 1:8840 CALUMET AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2545
Practice Address - Country:US
Practice Address - Phone:219-836-7246
Practice Address - Fax:219-836-6454
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045126A208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01045126AOtherBCBS OF ILLINOIS
IN01045126AOtherLICENSE NUMBER
IN200111560AMedicaid
GA050043847OtherMEDICARE RAILROAD
IN000000330844OtherBLUE CROSS BLUE SHIELD
IN01045126AOtherLICENSE NUMBER
INF73358Medicare UPIN