Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | 01074968A | IN |
NPI | 1184012130 |
---|---|
Provider Name | Hari Rasad Gourabathini |
First Address | South Bend, IN 46617-1924 |
Second Address | South Bend, IN 46601-1033 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2014 |
Last Update Date | 30/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
300012715 | (05) | IN |