Provider Demographics
NPI:1114281383
Name:PUSULURI, BHASKAR (MD)
Entity Type:Individual
Prefix:
First Name:BHASKAR
Middle Name:
Last Name:PUSULURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602530
Mailing Address - Street 2:500 JEFFERSON STREET
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2530
Mailing Address - Country:US
Mailing Address - Phone:910-642-1776
Mailing Address - Fax:910-642-9305
Practice Address - Street 1:500 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3634
Practice Address - Country:US
Practice Address - Phone:910-642-1776
Practice Address - Fax:910-642-9305
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01620207R00000X, 208M00000X
MD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2506Medicaid
NC1114281383Medicaid
NCNCP541CMedicare PIN
NCNCP541AMedicare PIN
NCNCP541DMedicare PIN
NCNCP541BMedicare PIN