Provider Demographics
NPI:1023113693
Name:CHALASANI, PADMAJA (MD)
Entity type:Individual
Prefix:
First Name:PADMAJA
Middle Name:
Last Name:CHALASANI
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 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-300-1129
Mailing Address - Fax:419-394-0255
Practice Address - Street 1:GRAND LAKE PRIMARY CARE AT ST MARYS
Practice Address - Street 2:1140 S KNOXVILLE AVE STE A
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2609
Practice Address - Country:US
Practice Address - Phone:419-394-9959
Practice Address - Fax:419-394-0255
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.074537207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934723OtherORGANIZATIONAL MEDICARE PTAN
OHH348972OtherMEDICARE PTAN
OH2079076Medicaid
OH0401314OtherUNITED HEALTHCARE
OH0855293Medicare PIN
OH0401314OtherUNITED HEALTHCARE