Provider Demographics
NPI:1326150988
Name:MENON, MURALEEDHARA (MD)
Entity Type:Individual
Prefix:
First Name:MURALEEDHARA
Middle Name:
Last Name:MENON
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 1:120 ROY CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9488
Mailing Address - Country:US
Mailing Address - Phone:606-439-2662
Mailing Address - Fax:606-439-0575
Practice Address - Street 1:1908 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2505
Practice Address - Country:US
Practice Address - Phone:606-439-2662
Practice Address - Fax:606-439-0575
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34546208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64003080Medicaid
KY64003080Medicaid
KYH11355Medicare UPIN
KY0501413Medicare ID - Type Unspecified
183857Medicare PIN