=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780630343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INDIRA NANNAPANENI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 07/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2606 WALES AVE NW SUITE 100
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-834-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2606 WALES AVE NW SUITE 100
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-834-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 35-07-7887 N
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------