Healthcare Provider Details

I. General information

NPI: 1104188077
Provider Name (Legal Business Name): SHIVKUMAR KAMBHAMPATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 04/22/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
CHESTER PA
19013-3902
US

IV. Provider business mailing address

PO BOX 3247
EVANSVILLE IN
47731-3247
US

V. Phone/Fax

Practice location:
  • Phone: 610-447-2500
  • Fax:
Mailing address:
  • Phone: 812-471-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberD0079989
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0079989
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116024813
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD463556
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: