Healthcare Provider Details

I. General information

NPI: 1669415592
Provider Name (Legal Business Name): INNANJE RAVINDRANATH RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E FRANKLIN ST SUITE B
MONROE NC
28112-5266
US

IV. Provider business mailing address

PO BOX 60122
CHARLOTTE NC
28260-0122
US

V. Phone/Fax

Practice location:
  • Phone: 704-283-6953
  • Fax: 704-283-0228
Mailing address:
  • Phone: 704-512-4808
  • Fax: 704-512-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number19943
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: