Provider Demographics
NPI:1508862806
Name:VERVERELI, PRODROMOS A (MD)
Entity Type:Individual
Prefix:
First Name:PRODROMOS
Middle Name:A
Last Name:VERVERELI
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 1:400 ELK CHASE CT
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-7260
Mailing Address - Country:US
Mailing Address - Phone:610-390-8228
Mailing Address - Fax:
Practice Address - Street 1:400 ELK CHASE CT
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-7260
Practice Address - Country:US
Practice Address - Phone:610-390-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044774L207XS0114X
KY55069207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015347530003Medicaid
PA0292440001Medicare NSC
PA0015347530003Medicaid
PAG04132Medicare UPIN
PA703188DW3Medicare PIN