Healthcare Provider Details

I. General information

NPI: 1568490118
Provider Name (Legal Business Name): KIRAN RAM KURICHETY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 S RIFE MEDICAL LN STE 220
ROGERS AR
72758
US

IV. Provider business mailing address

2708 S RIFE MEDICAL LN STE 220
ROGERS AR
72758-1456
US

V. Phone/Fax

Practice location:
  • Phone: 479-338-4400
  • Fax: 479-338-4445
Mailing address:
  • Phone: 479-338-4400
  • Fax: 479-338-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL9301
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberL9301
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberL9301
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberL9301
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE12282
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: