=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497043236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NISCHALA RAJEGOWDA M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2011
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 TRILLIUM WAY
-----------------------------------------------------
City | CORBIN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40701-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-523-8620
-----------------------------------------------------
Fax | 606-523-8706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1325
-----------------------------------------------------
City | CORBIN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40702-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-526-8131
-----------------------------------------------------
Fax | 606-528-8661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 51002
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------