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General NPI Number Information
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NPI Number | 1437399037
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Entity Type | Organization
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Legal Business Name | SURESH KODALI
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Dates
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Enumeration Date | 02/23/2009
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Last Update Date | 02/09/2016
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Provider Practice Location Address
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Address Line | 708 WESTPORT RD SUITE 103
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-3819
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Country | US
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Telephone | 270-766-1234
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Fax | 270-766-1144
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Provider Business Mailing Address
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Address Line | 708 WESTPORT RD SUITE 103
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-3819
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Country | US
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Telephone | 270-766-1234
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Fax | 270-766-1144
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Authorized Official
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Title or Position | PROVIDER
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Name | SURESH B KODALI
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Credential | M.D.
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Telephone | 270-766-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0726
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License Number State | KY
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