=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134439300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL INPATIENT MEDICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2010
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 E JUNIPER WAY
-----------------------------------------------------
City | HARTLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53029-8670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-695-2797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 E JUNIPER WAY
-----------------------------------------------------
City | HARTLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53029-8670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-695-2797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | SRINIVISA R PAMULAPATI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 262-695-2797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------