Provider Demographics
NPI:1831626688
Name:L CHIRUMAMILLA, MD, PC
Entity type:Organization
Organization Name:L CHIRUMAMILLA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-989-5495
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-0511
Mailing Address - Country:US
Mailing Address - Phone:812-987-2294
Mailing Address - Fax:
Practice Address - Street 1:3058 WOLF LAKE BLVD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9584
Practice Address - Country:US
Practice Address - Phone:812-987-2294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046148A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty