Provider Demographics
NPI:1679591374
Name:CHIVUKULA, SUBRAHMANYAM (MD FACC)
Entity Type:Individual
Prefix:DR
First Name:SUBRAHMANYAM
Middle Name:
Last Name:CHIVUKULA
Suffix:
Gender:M
Credentials:MD FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MILL STREET
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007
Mailing Address - Country:US
Mailing Address - Phone:215-785-5100
Mailing Address - Fax:215-785-5100
Practice Address - Street 1:245 MILL STREET
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007
Practice Address - Country:US
Practice Address - Phone:215-785-5100
Practice Address - Fax:215-785-5100
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 034229E207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4079599OtherAETNA
00220089000OtherHIGHMARK
PA0010137740003Medicaid
183376Medicare ID - Type Unspecified
C322996Medicare UPIN