Provider Demographics
NPI:1942486774
Name:MADHAVA T PALLY MD PA
Entity Type:Organization
Organization Name:MADHAVA T PALLY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHAVA
Authorized Official - Middle Name:T
Authorized Official - Last Name:PALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-303-9550
Mailing Address - Street 1:228 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6054
Mailing Address - Country:US
Mailing Address - Phone:239-303-9550
Mailing Address - Fax:239-303-9551
Practice Address - Street 1:228 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6054
Practice Address - Country:US
Practice Address - Phone:239-303-9550
Practice Address - Fax:239-303-9551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42506207R00000X, 207RC0000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1821005422OtherNPI, INDIVIDUAL
FL30597COtherMEDICARE, PTAN
FL067609800Medicaid
FL067609800Medicaid