Provider Demographics
NPI:1346554169
Name:PUCHALAPALLI M D, INC.
Entity Type:Organization
Organization Name:PUCHALAPALLI M D, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBBAREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCHALAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-3225
Mailing Address - Street 1:2250 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-3317
Mailing Address - Country:US
Mailing Address - Phone:812-232-3225
Mailing Address - Fax:812-232-4215
Practice Address - Street 1:2250 WABASH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3317
Practice Address - Country:US
Practice Address - Phone:812-232-3225
Practice Address - Fax:812-232-4215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046393A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200148980CMedicaid
IN186180Medicare PIN