Provider Demographics
NPI:1942209036
Name:KANCHERLA, MADHU KIRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHU
Middle Name:KIRAN
Last Name:KANCHERLA
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 1:10012 KENNERLY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-842-0602
Mailing Address - Fax:314-842-4372
Practice Address - Street 1:10012 KENNERLY RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-842-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103619207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204631212Medicaid
MO204631204Medicaid
MO023012206Medicare ID - Type UnspecifiedAREA 1
ILL71338Medicare PIN
060053893Medicare PIN
MOG94451Medicare UPIN
MO021012205Medicare ID - Type UnspecifiedAREA 99
MO204631204Medicaid