Provider Demographics
NPI:1992991137
Name:SUBBARAYUDU KOPPERA MD, INC
Entity type:Organization
Organization Name:SUBBARAYUDU KOPPERA MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBBARAYUDU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-622-6474
Mailing Address - Street 1:7594 OGDEN WOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-9635
Mailing Address - Country:US
Mailing Address - Phone:740-644-6474
Mailing Address - Fax:
Practice Address - Street 1:7594 OGDEN WOODS BLVD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-9635
Practice Address - Country:US
Practice Address - Phone:740-644-6474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBBARAYUDU KOPPERA MD,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-21
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9328362Medicare PIN