=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013063106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST KY PULMONARY & SLEEP DISORDER CTR.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 06/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9350 US HWY 23 SOUTH SUITE 104
-----------------------------------------------------
City | STANVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-478-1005
-----------------------------------------------------
Fax | 606-478-8687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70
-----------------------------------------------------
City | STANVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41659-0070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-478-1005
-----------------------------------------------------
Fax | 606-478-8687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SRINIVAS AMMISETTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 606-478-1005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35594
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35594
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 35594
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------