Provider Demographics
NPI:1578623278
Name:MADHIPATLA, VENU M (MD)
Entity Type:Individual
Prefix:
First Name:VENU
Middle Name:M
Last Name:MADHIPATLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1413 CHATTANOOGA AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2631
Mailing Address - Country:US
Mailing Address - Phone:706-279-2635
Mailing Address - Fax:706-279-2679
Practice Address - Street 1:715 QUEEN CITY PKWY STE 106
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4335
Practice Address - Country:US
Practice Address - Phone:678-450-1222
Practice Address - Fax:706-279-2679
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY002716207L00000X
GA65559207L00000X, 207RC0200X
IN01067687A208VP0000X
GA065559207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200973980Medicaid
KY7100117730Medicaid
GA003104831NMedicaid
GA003104831AMedicaid
GA202I056420Medicare PIN