Provider Demographics
NPI:1295742849
Name:TANNERU, PADMAJA R (MD)
Entity type:Individual
Prefix:
First Name:PADMAJA
Middle Name:R
Last Name:TANNERU
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 1:120 MCMILLEN DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1809
Mailing Address - Country:US
Mailing Address - Phone:220-564-1765
Mailing Address - Fax:220-564-1766
Practice Address - Street 1:7657 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1243
Practice Address - Country:US
Practice Address - Phone:614-865-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088340207P00000X
OH35088340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2674155Medicaid
OHH143251Medicare PIN