Provider Demographics
NPI:1639126337
Name:YALAMANCHILI, B R (MD)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:R
Last Name:YALAMANCHILI
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:PO BOX 182255
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-2255
Mailing Address - Country:US
Mailing Address - Phone:513-852-2442
Mailing Address - Fax:614-430-5742
Practice Address - Street 1:320 LORETTO RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1300
Practice Address - Country:US
Practice Address - Phone:270-692-5158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY219362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000071071OtherANTHEM
KY64781651Medicaid
KY1904201Medicare ID - Type Unspecified
000000071071OtherANTHEM