Provider Demographics
NPI:1477571925
Name:KESRI, SAM REDDY (MD)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:REDDY
Last Name:KESRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHYAM
Other - Middle Name:MURALI
Other - Last Name:KEESARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6040 SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-0388
Mailing Address - Country:US
Mailing Address - Phone:270-842-5850
Mailing Address - Fax:270-842-5388
Practice Address - Street 1:6040 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-0388
Practice Address - Country:US
Practice Address - Phone:270-842-5850
Practice Address - Fax:270-842-5388
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64338049Medicaid
1721201Medicare ID - Type Unspecified
KY64338049Medicaid