Provider Demographics
NPI:1487988028
Name:SUJANA K PATIBANDLA MD INC
Entity type:Organization
Organization Name:SUJANA K PATIBANDLA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUJANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PATIBANDLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-492-5210
Mailing Address - Street 1:4186 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2532
Mailing Address - Country:US
Mailing Address - Phone:330-492-5210
Mailing Address - Fax:330-492-5230
Practice Address - Street 1:4186 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2532
Practice Address - Country:US
Practice Address - Phone:330-492-5210
Practice Address - Fax:330-492-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0505742Medicaid
OHA15228Medicare UPIN
OH0505742Medicaid