Basic Information
Provider Information | |||||||||
NPI: | 1992135073 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REPALA | ||||||||
FirstName: | BINDU | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2518 JIMMY LEE SMITH PKWY | ||||||||
Address2: |   | ||||||||
City: | HIRAM | ||||||||
State: | GA | ||||||||
PostalCode: | 301412068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4706448027 | ||||||||
FaxNumber: | 4706448064 | ||||||||
Practice Location | |||||||||
Address1: | 6700 FALLSTONE RD | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729168958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6308420067 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2013 | ||||||||
LastUpdateDate: | 10/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | EE8303 | AR | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 77902 | GA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.