Provider Demographics
NPI:1649995382
Name:PRASAD POLISETTY MD PLLC
Entity type:Organization
Organization Name:PRASAD POLISETTY MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-646-1862
Mailing Address - Street 1:204 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3655
Mailing Address - Country:US
Mailing Address - Phone:248-633-4262
Mailing Address - Fax:
Practice Address - Street 1:120 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-487-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-05
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No283X00000XHospitalsRehabilitation HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1376711291Medicaid