Provider Demographics
NPI:1548356678
Name:ANNE, MALLIKARJUNA (MD)
Entity type:Individual
Prefix:
First Name:MALLIKARJUNA
Middle Name:
Last Name:ANNE
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 3133
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3043
Practice Address - Country:US
Practice Address - Phone:312-770-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044990207ZC0500X, 207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634127OtherBCBS IL
IL036044990Medicaid
E30343Medicare UPIN
ILK04069Medicare PIN