MEDICARE: DR. MANGARAJU KOLLURU 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	208000000X	Pediatrics Physician	26290	NC
2	208D00000X	General Practice Physician	26290	NC

General Provider Information

NPI Number	:	1346250800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANGARAJU KOLLURU M.D.

Provider Business Mailing Address
First Line	:	1101 RIVER RD
Second Line	:
City	:	SELMA
State	:	NC
Zip	:	27576-3611
Country	:	US
Telephone Number	:	919-965-6550
Fax Number	:	919-975-1029

Provider Business Practice Location Address
First Line	:	1101 RIVER RD
Second Line	:
City	:	SELMA
State	:	NC
Zip	:	27576-3611
Country	:	US
Telephone Number	:	919-965-9655
Fax Number	:	919-975-1029

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	09/21/2012

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