Provider Demographics
NPI:1922205681
Name:PALLA, AMRUTH R (MD)
Entity Type:Individual
Prefix:
First Name:AMRUTH
Middle Name:R
Last Name:PALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 ARBOR VITAE LN
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 CAMPUS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-8489
Practice Address - Country:US
Practice Address - Phone:989-839-6188
Practice Address - Fax:989-839-6221
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2015030942207RH0003X
WI72774207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11716653OtherCAQH NUMBER