Basic Information
Provider Information | |||||||||
NPI: | 1881885911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SATHEESH | ||||||||
FirstName: | SREEKALA | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PURUSHOTHAMAN | ||||||||
OtherFirstName: | SREEKALA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3495 PIEDMONT ROAD | ||||||||
Address2: | NINE PIEDMONT CENTER | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042529307 | ||||||||
FaxNumber: | 4042525839 | ||||||||
Practice Location | |||||||||
Address1: | 20 GLENLAKE PARKWAY | ||||||||
Address2: | KAISER PERMANENTE GLENLAKE MEDICAL CENTER | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706776247 | ||||||||
FaxNumber: | 4042525839 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2007 | ||||||||
LastUpdateDate: | 02/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 062602 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | CB5609 | 01 | GA | RAILROAD MEDICARE | OTHER | GRP1077 | 01 | GA | MEDICARE GROUP | OTHER |