Healthcare Provider Details

I. General information

NPI: 1073133179
Provider Name (Legal Business Name): SREE CHELLAPPAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W 40TH AVE STE 100
PINE BLUFF AR
71603-6069
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-6000
  • Fax: 870-541-6010
Mailing address:
  • Phone: 800-893-9698
  • Fax: 870-541-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE15648
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101281549
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-15648
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: