MEDICARE: PADMAJA CHALASANI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35.074537	OH
2	207R00000X	Internal Medicine Physician	35.074537	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9934723	OTHER	OH	ORGANIZATIONAL MEDICARE PTAN
2	H348972	OTHER	OH	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023113693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PADMAJA CHALASANI M.D.

Provider Business Mailing Address
First Line	:	200 SAINT CLAIR AVE
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2400
Country	:	US
Telephone Number	:	419-300-1129
Fax Number	:	419-394-0255

Provider Business Practice Location Address
First Line	:	GRAND LAKE PRIMARY CARE AT ST MARYS
Second Line	:	1140 S KNOXVILLE AVE STE A
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2609
Country	:	US
Telephone Number	:	419-394-9959
Fax Number	:	419-394-0255

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	01/24/2022

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Directions to “ PADMAJA CHALASANI M.D.” Practice Location

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