Basic Information
Provider Information | |||||||||
NPI: | 1487695318 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THUPPAL | ||||||||
FirstName: | MADHAVAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 ROBB HOLLOW RD | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152431700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4122780477 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 FORT COUCH RD | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152411030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4128311223 | ||||||||
FaxNumber: | 4128311034 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2006 | ||||||||
LastUpdateDate: | 07/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | MD-070792-L | PA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | MD-070792-L | PA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | MD070792L | PA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 928263 | 01 | PA | HIGHMARK | OTHER | 0018224090003 | 05 | PA |   | MEDICAID | 7180402 | 01 | PA | AETNA | OTHER | 469699 | 01 | PA | VALUE OPTIONS | OTHER |