Healthcare Provider Details

I. General information

NPI: 1891851812
Provider Name (Legal Business Name): SRI KIRAN CHENNUPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 S CEDAR CREST BLVD SUITE 1100
ALLENTOWN PA
18103-6229
US

IV. Provider business mailing address

PO BOX 783311
PHILADELPHIA PA
19178-3311
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-7999
  • Fax: 610-402-7995
Mailing address:
  • Phone: 484-884-4500
  • Fax: 484-884-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMT184710
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD431213
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number25MA08862500
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD431213
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: