Basic Information
| Provider Information | |||||||||
| NPI: | 1407012040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KARUMBAIAH | ||||||||
| FirstName: | KEERTHANA | ||||||||
| MiddleName: | KALENGADA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MEMORIAL DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 GLENNDALE RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065984500 | ||||||||
| FaxNumber: | 6065992540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 47163 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 7100301520 | 05 | KY | MEDICAID |