=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588785505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PULMONARY ASSOC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 11/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 979 E 3RD ST SUITE B-1201
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-778-5864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11562
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37401-2562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-778-5864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SURESH ENJETI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 423-778-5864
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------