MEDICARE: DR. MIHAS MAMU KODENCHERY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	4301087486	MI
2	390200000X	Student in an Organized Health Care Education/Training Program	4301087486	MI
3	207RC0000X	Cardiovascular Disease Physician	01072452A	IN

General Provider Information

NPI Number	:	1013111475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIHAS MAMU KODENCHERY MD

Provider Business Mailing Address
First Line	:	5800 BROADWAY
Second Line	:	SUITE A-J
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-2601
Country	:	US
Telephone Number	:	219-884-9185
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 BROADWAY
Second Line	:	SUITE A-J
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-2601
Country	:	US
Telephone Number	:	219-884-9185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	02/09/2014

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