Provider Demographics
NPI:1083855993
Name:BHATRAJU MEDICAL CLINIC
Entity Type:Organization
Organization Name:BHATRAJU MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:606-432-0168
Mailing Address - Street 1:180 TOWN MOUNTAIN RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1698
Mailing Address - Country:US
Mailing Address - Phone:606-432-0168
Mailing Address - Fax:
Practice Address - Street 1:180 TOWN MOUNTAIN RD
Practice Address - Street 2:SUITE 111
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1698
Practice Address - Country:US
Practice Address - Phone:606-432-0168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA953208D00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty