Provider Demographics
NPI:1821103995
Name:VANTERPOOL, KISHA (MD)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:VANTERPOOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5652
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-9403
Practice Address - Fax:215-225-1698
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429577207R00000X, 208M00000X
IL036139805208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017395200003Medicaid
PA2855050000OtherBCBS OF PA
PA2094018OtherHIGHMARK BLUE SHIELD
PA1017395200001Medicaid
PA1017395200002Medicaid
PA106263VYNMedicare PIN
PA2855050000OtherBCBS OF PA