Healthcare Provider Details

I. General information

NPI: 1154461572
Provider Name (Legal Business Name): KANCHERLA RAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 S BROADWAY
LORAIN OH
44053-3821
US

IV. Provider business mailing address

11124 WOODBURY LANE
ELYRIA OH
44035
US

V. Phone/Fax

Practice location:
  • Phone: 440-204-4364
  • Fax: 440-233-9070
Mailing address:
  • Phone: 440-877-1859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number35046832
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: