Basic Information
| Provider Information | |||||||||
| NPI: | 1821005422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALLY | ||||||||
| FirstName: | MADHAVA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2316 PATRINOSTRO RD | ||||||||
| Address2: | |||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335657228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882460313 | ||||||||
| FaxNumber: | 8882471186 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SLATE CREEK RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | GRUNDY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246146975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769351640 | ||||||||
| FaxNumber: | 6062184697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME42506 | FL | N | Other Service Providers | Specialist | 207RC0000X | 0101263918 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 067609800 | 05 | FL | MEDICAID |