Basic Information
| Provider Information | |||||||||
| NPI: | 1770504656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JETTY | ||||||||
| FirstName: | SATHISH | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407797795 | ||||||||
| FaxNumber: | 7407794257 | ||||||||
| Practice Location | |||||||||
| Address1: | 4439 STATE ROUTE 159 | ||||||||
| Address2: | STE G10 | ||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794300 | ||||||||
| FaxNumber: | 7407794390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 35.064617 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 35.064617 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0952625 | 05 | OH | MEDICAID |