Healthcare Provider Details

I. General information

NPI: 1922205681
Provider Name (Legal Business Name): AMRUTH R PALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CAMPUS RIDGE DR
MIDLAND MI
48670-8489
US

IV. Provider business mailing address

410 ARBOR VITAE LN
DE PERE WI
54115-8489
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-6188
  • Fax: 989-839-6221
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2015030942
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number72774
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number72774
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: