Provider Demographics
NPI:1992897680
Name:CHANAMOLU, SREENIVASA RAO (MD,)
Entity type:Individual
Prefix:DR
First Name:SREENIVASA
Middle Name:RAO
Last Name:CHANAMOLU
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:800-514-4390
Mailing Address - Fax:440-808-3676
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:419-996-2686
Practice Address - Fax:419-996-5165
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088188207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2691305Medicaid
OH2691305Medicaid
OH4194681Medicare PIN