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General NPI Number Information
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NPI Number | 1083855993
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Entity Type | Organization
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Legal Business Name | BHATRAJU MEDICAL CLINIC
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Dates
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Enumeration Date | 03/23/2009
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Last Update Date | 03/23/2009
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Provider Practice Location Address
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Address Line | 180 TOWN MOUNTAIN RD SUITE 111
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City | PIKEVILLE
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State | KY
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Zip | 41501-1698
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Country | US
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Telephone | 606-432-0168
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Fax |
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Provider Business Mailing Address
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Address Line | 180 TOWN MOUNTAIN RD SUITE 111
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City | PIKEVILLE
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State | KY
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Zip | 41501-1698
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Country | US
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Telephone | 606-432-0168
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Fax |
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Authorized Official
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Title or Position | PA-MANAGER
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Name | ALLEN MAYNARD
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Credential | PA-C
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Telephone | 606-432-0168
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | PA953
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | PA953
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License Number State | KY
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