=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679591374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUBRAHMANYAM CHIVUKULA MD FACC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 MILL STREET
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-785-5100
-----------------------------------------------------
Fax | 215-785-5100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 MILL STREET
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-785-5100
-----------------------------------------------------
Fax | 215-785-5100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | MD 034229E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------