Basic Information
| Provider Information | |||||||||
| NPI: | 1518183821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STELLAR HEALTH CARE ASSOCIATES INC., | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | SMITHS GROVE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421710399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705633000 | ||||||||
| FaxNumber: | 2705632801 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 COLLEGE STREET | ||||||||
| Address2: | |||||||||
| City: | SMITHS GROVE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705633000 | ||||||||
| FaxNumber: | 2705632801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | AVULA | ||||||||
| AuthorizedOfficialFirstName: | PRAVIN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2705633000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31173 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64311731 | 05 | KY | MEDICAID |