Healthcare Provider Details

I. General information

NPI: 1376552901
Provider Name (Legal Business Name): MANGADHARA RAO MADINEEDI MD, MSA, FACP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/07/2023
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST GERIATRICS & EXTENDED CARE SERVICE LINE (181)
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

940 BELMONT ST
BROCKTON MA
02301-5596
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-1860
  • Fax: 774-826-2643
Mailing address:
  • Phone: 508-583-4500
  • Fax: 774-826-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number79686
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number79686
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: