Basic Information
| Provider Information | |||||||||
| NPI: | 1043263346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SESHABHATTAR | ||||||||
| FirstName: | PRAVEEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6801 DIXIE HWY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402583913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023673360 | ||||||||
| FaxNumber: | 5023673365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 BLUEGRASS AVE | ||||||||
| Address2: | HIPS DEPT | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023673360 | ||||||||
| FaxNumber: | 5023673365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35087541 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 42999 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 42999 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100154080 | 05 | KY | MEDICAID | 201062650 | 05 | IN | MEDICAID | PENDING | 05 | OH | MEDICAID |