Provider Demographics
NPI:1760609853
Name:KRISHNA KUMAR PUDI MD PA
Entity Type:Organization
Organization Name:KRISHNA KUMAR PUDI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE PROCESSOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-963-9090
Mailing Address - Street 1:110A HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3226
Mailing Address - Country:US
Mailing Address - Phone:864-963-9090
Mailing Address - Fax:864-962-0610
Practice Address - Street 1:110A HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3226
Practice Address - Country:US
Practice Address - Phone:864-963-9090
Practice Address - Fax:864-962-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty