Provider Demographics
NPI:1912161076
Name:CHINNAIRUSAN, MUTHAMILAN (MD)
Entity Type:Individual
Prefix:
First Name:MUTHAMILAN
Middle Name:
Last Name:CHINNAIRUSAN
Suffix:
Gender:M
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:PO BOX 1079
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1079
Mailing Address - Country:US
Mailing Address - Phone:270-827-0353
Mailing Address - Fax:270-827-4966
Practice Address - Street 1:1997 BARRETT CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2667
Practice Address - Country:US
Practice Address - Phone:270-826-3538
Practice Address - Fax:270-827-2779
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41979208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100053500Medicaid
KY000000575930OtherANTHEM BC BS
KY7100053500Medicaid