Provider Demographics
NPI:1881768075
Name:KANNEGANTI, MADHAVI (MD)
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:KANNEGANTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11670 MARTIN
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-754-3830
Mailing Address - Fax:586-754-3840
Practice Address - Street 1:11670 MARTIN
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-754-3830
Practice Address - Fax:586-754-3840
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK058470207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP49707OtherBCN
MI3357489Medicaid
G46360Medicare UPIN
MI3357489Medicaid