Basic Information
Provider Information | |||||||||
NPI: | 1972749174 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAKKALA | ||||||||
FirstName: | SAILESH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 20TH AVE N STE 403 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372035180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153964694 | ||||||||
FaxNumber: | 6153966751 | ||||||||
Practice Location | |||||||||
Address1: | 1700 MEDICAL CENTER PKWY | ||||||||
Address2: |   | ||||||||
City: | MURFREESBORO | ||||||||
State: | TN | ||||||||
PostalCode: | 371292245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153964694 | ||||||||
FaxNumber: | 6153966751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2008 | ||||||||
LastUpdateDate: | 12/28/2018 | ||||||||
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 | 174400000X | 44470 | TN | N |   | Other Service Providers | Specialist |   | 208M00000X | 44470 | TN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 44470 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | TN |   | MEDICAID |