1629059431 NPI number — LEELA BHUPALAM MD

Table of content: LEELA BHUPALAM MD (NPI 1629059431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629059431 NPI number — LEELA BHUPALAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BHUPALAM
Provider First Name:
LEELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629059431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950237
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-238-2801
Provider Business Mailing Address Fax Number:
502-238-2835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4003 KRESGE WAY
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-1166
Provider Business Practice Location Address Fax Number:
502-897-1461
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  29062 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64290620 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50027633 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000652541 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3770175000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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