Provider Demographics
NPI:1700891454
Name:PERUMANDLA, SIRISHA (MBBS)
Entity Type:Individual
Prefix:
First Name:SIRISHA
Middle Name:
Last Name:PERUMANDLA
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:520 TECHWOOD DR N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8500
Mailing Address - Country:US
Mailing Address - Phone:859-936-9844
Mailing Address - Fax:859-236-0320
Practice Address - Street 1:520 TECHWOOD DR N
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8500
Practice Address - Country:US
Practice Address - Phone:859-236-2203
Practice Address - Fax:859-238-2206
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36765207R00000X, 207RH0003X
KYTP947207RH0003X
KY44696207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61-1277847OtherUNITED HEALTHCARE
KY7531832OtherAETNA
IA1499426Medicaid
25031OtherBLUE CROSS/BLUE SHIELD
KY50034241OtherPASSPORT HEALTH PLAN/PASSPORT ADVANTAGE
1700891454OtherTRICARE
KY87090OtherCOVENTRYCARES OF KENTUCKY
IAZZ207RH00033XMedicaid
KY170891454OtherHUMANA
IA25208OtherWELLMARK BCBS
IAI8485Medicare PIN
KY50034241OtherPASSPORT HEALTH PLAN/PASSPORT ADVANTAGE
IA25208OtherWELLMARK BCBS
H77119Medicare UPIN