MEDICARE: DR. CHANCHAMMA THANNIKKARY 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	2085R0001X	Radiation Oncology Physician	32057	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01269393	OTHER	NC	RAILROAD MCR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3722179	OTHER	NC	CIGNA
4	5760043	OTHER	NC	AETNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881654085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANCHAMMA THANNIKKARY M.D.

Provider Business Mailing Address
First Line	:	2234 COLONIAL BLVD
Second Line	:	ATTN: PAYER CONTRACTING & RELATIONS
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1412
Country	:	US
Telephone Number	:	239-931-7342
Fax Number	:	239-931-7385

Provider Business Practice Location Address
First Line	:	212 SMITH CHURCH RD
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-4914
Country	:	US
Telephone Number	:	252-537-1717
Fax Number	:	252-537-1366

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

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	03/21/2014

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