Healthcare Provider Details

I. General information

NPI: 1962459099
Provider Name (Legal Business Name): BENERJI GUDAPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WABASH
MARION IN
46952-2612
US

IV. Provider business mailing address

330 N WABASH STE G20
MARION IN
46952-2600
US

V. Phone/Fax

Practice location:
  • Phone: 765-660-6000
  • Fax:
Mailing address:
  • Phone: 765-660-7600
  • Fax: 765-651-7313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061188A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01061188A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: