Healthcare Provider Details

I. General information

NPI: 1821817503
Provider Name (Legal Business Name): AMKY MSO-1 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W WHITTAKER ST STE D
SALEM IL
62881-2034
US

IV. Provider business mailing address

1325 W WHITTAKER ST STE D
SALEM IL
62881-2034
US

V. Phone/Fax

Practice location:
  • Phone: 678-982-3590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. YUGANDHAR KANDIMALLA
Title or Position: PRESIDENT
Credential: MD
Phone: 678-982-3590