Provider Demographics
NPI:1164431284
Name:KETHA, SIVA SANKAR (MD)
Entity Type:Individual
Prefix:
First Name:SIVA
Middle Name:SANKAR
Last Name:KETHA
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 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:3324 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7233
Practice Address - Country:US
Practice Address - Phone:919-781-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96490207R00000X
MN52266207R00000X
MN104267207R00000X
NC2018-01920207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC202WDOtherBCBS OF NC
IAENROLLEDMedicaid
MNP00918758OtherRAILROAD MEDICARE
NC1164431284Medicaid
FL276408300Medicaid
MNENROLLEDMedicaid
NCNN6996AOtherMEDICARE