Basic Information
| Provider Information | |||||||||
| NPI: | 1053686808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALLAVALA | ||||||||
| FirstName: | REDDY RUPA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E. 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 S STATE ROAD 135 | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461439825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174972400 | ||||||||
| FaxNumber: | 3174972515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 01073752A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201227860 | 05 | IN | MEDICAID | P01347731 | 01 | IN | MEDICARE RR PTAN | OTHER |