Healthcare Provider Details

I. General information

NPI: 1922791839
Provider Name (Legal Business Name): KSP HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 300
ST PETERSBURG FL
33702-4399
US

IV. Provider business mailing address

6505 E CENTRAL AVE STE 183
WICHITA KS
67206-1924
US

V. Phone/Fax

Practice location:
  • Phone: 316-516-2853
  • Fax:
Mailing address:
  • Phone: 31-651-6285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MUTHUKUMAR VELLAICHAMY
Title or Position: OWNER
Credential: MD
Phone: 316-516-2853