=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871961144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUGLAIZE MERCER CARDIOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 09/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 03920 SOUTHLAND RD
-----------------------------------------------------
City | NEW BREMEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45869-9790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-629-3663
-----------------------------------------------------
Fax | 419-629-2783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 03920 SOUTHLAND RD
-----------------------------------------------------
City | NEW BREMEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45869-9790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-629-3663
-----------------------------------------------------
Fax | 419-629-2783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAJENDRA KAKARLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 419-629-3663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 35062730
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------