=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922372812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANDRASEKHAR POLEPALLE MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2012
-----------------------------------------------------
Last Update Date | 02/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3720 W BROADWAY ST
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74401-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-683-5939
-----------------------------------------------------
Fax | 918-686-5590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3720 W BROADWAY ST
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74401-2141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-683-5939
-----------------------------------------------------
Fax | 918-686-5590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHERRY HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-683-5939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------