Provider Demographics
NPI:1104890920
Name:MURTHY, SIVA R (MD)
Entity type:Individual
Prefix:
First Name:SIVA
Middle Name:R
Last Name:MURTHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1106 COLEGATE DR
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1323
Practice Address - Country:US
Practice Address - Phone:740-568-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050136207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015546Medicaid
OH0078416Medicaid
OHP01251552OtherRAILROAD MEDICARE - MHCPI
OHH177751Medicare PIN
OHH051400Medicare PIN
OH0078416Medicaid
A17669Medicare UPIN