Healthcare Provider Details

I. General information

NPI: 1578818639
Provider Name (Legal Business Name): SUDHEER PENUPOLU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH ACADEMY AVENUE
DANVILLE PA
17822
US

IV. Provider business mailing address

100 NORTH ACADEMY AVENUE
DANVILLE PA
17822
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6655
  • Fax: 570-214-3967
Mailing address:
  • Phone: 570-271-6655
  • Fax: 570-214-3967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR73194
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD454637
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD454637
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: