Basic Information
| Provider Information | |||||||||
| NPI: | 1114183449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEERTHAM | ||||||||
| FirstName: | MUNI | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657763020 | ||||||||
| FaxNumber: | 7654538111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301091596 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01069020A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000724294 | 01 | IN | ANTHEM | OTHER | 1114183449 | 01 | RR PTAN | OTHER | 201025960 | 05 | IN | MEDICAID |