Healthcare Provider Details

I. General information

NPI: 1891792818
Provider Name (Legal Business Name): MAHENDRA C MARU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 E PARRISH AVE
OWENSBORO KY
42303-1443
US

IV. Provider business mailing address

1930 E PARRISH AVE
OWENSBORO KY
42303-1443
US

V. Phone/Fax

Practice location:
  • Phone: 270-689-1919
  • Fax: 270-689-1990
Mailing address:
  • Phone: 270-689-1919
  • Fax: 270-689-1990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number33042
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33042
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: