Provider Demographics
NPI:1851332829
Name:TAMIRISA, KIRAN C (MD)
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:C
Last Name:TAMIRISA
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 1:2600 NAVARRE AVE
Mailing Address - Street 2:PAIN CLINIC
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3207
Practice Address - Country:US
Practice Address - Phone:419-696-7646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045601207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000185388OtherBCBS
OH0440866Medicaid
MI4272949-10Medicaid
OH050078198Medicare ID - Type UnspecifiedRAILROAD
OHTA0495885Medicare ID - Type Unspecified
OH0440866Medicaid