Provider Demographics
NPI:1790710218
Name:MAMIDI, SATYANARAYANA M (MD)
Entity Type:Individual
Prefix:
First Name:SATYANARAYANA
Middle Name:M
Last Name:MAMIDI
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 1:1300 CLARK ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-8875
Mailing Address - Country:US
Mailing Address - Phone:740-439-5107
Mailing Address - Fax:740-439-5183
Practice Address - Street 1:1300 CLARK ST UNIT 7
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-8875
Practice Address - Country:US
Practice Address - Phone:740-439-5107
Practice Address - Fax:740-439-5183
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12853207RC0000X
OH35-045590207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
001705987OtherMOUNTAINSTATE BLUECROSS B
OH0517435Medicaid
11-3703997OtherTAX ID
DA3951OtherRAILROAD MEDICARE
113703997 0004OtherCIGNA HEALTHCARE
OH4047524Medicare PIN
11-3703997OtherTAX ID
OH0517435Medicaid