Healthcare Provider Details

I. General information

NPI: 1528099090
Provider Name (Legal Business Name): SREENIVASAN C KOTAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1763 PARK AVE SW
NORTON VA
24273-1608
US

IV. Provider business mailing address

999 EXECUTIVE PARK BLVD SUITE 201
KINGSPORT TN
37660-4632
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-1700
  • Fax: 276-679-6243
Mailing address:
  • Phone: 423-224-3250
  • Fax: 423-224-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101031294
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: