Provider Demographics
NPI:1558335919
Name:KOSARAJU, SIVASANKARA RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVASANKARA
Middle Name:RAO
Last Name:KOSARAJU
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 1:130 S BRYN MAWR AVE
Mailing Address - Street 2:SUITE H-321
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3121
Mailing Address - Country:US
Mailing Address - Phone:610-526-4097
Mailing Address - Fax:610-526-4082
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:SUITE H-321
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:610-526-4097
Practice Address - Fax:610-526-4082
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426808207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMAIN LINE HEALTHCARE
PA101319122Medicaid
PA092766N2PMedicare ID - Type Unspecified
I34996Medicare UPIN