Healthcare Provider Details

I. General information

NPI: 1962717785
Provider Name (Legal Business Name): SIRISH KUMAR PALLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 KATE IRELAND DR
HYDEN KY
41749-9071
US

IV. Provider business mailing address

130 KATE IRELAND DR
HYDEN KY
41749-9071
US

V. Phone/Fax

Practice location:
  • Phone: 606-672-2901
  • Fax:
Mailing address:
  • Phone: 606-672-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45469
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: