Provider Demographics
NPI:1528566254
Name:BANGARURAJU KOLANUVADA MEDICAL PC
Entity Type:Organization
Organization Name:BANGARURAJU KOLANUVADA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:BANGARURAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLANUVADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-720-1047
Mailing Address - Street 1:1 FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 N BROADWAY STE 206
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1310
Practice Address - Country:US
Practice Address - Phone:914-969-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02499383Medicaid