Provider Demographics
NPI:1467685073
Name:BHARATH, KOMAL (MD)
Entity type:Individual
Prefix:DR
First Name:KOMAL
Middle Name:
Last Name:BHARATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KOMALAVALLI
Other - Middle Name:
Other - Last Name:VENKATAKRISHNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1601 CHESTNUT ST
Mailing Address - Street 2:2 LIBERTY PLACE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19192-0001
Mailing Address - Country:US
Mailing Address - Phone:267-838-2061
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2844
Practice Address - Fax:215-214-1425
Is Sole Proprietor?:No
Enumeration Date:2009-08-30
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD443523208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA037276OtherMLHC MEDICARE AA #
PA100727800OtherTPI MEDICAID GROUP
PACD4829OtherTPI RAILROAD MEDICARE GROUP
PA597586OtherTPI MEDICARE GROUP PIN
PA824305OtherMLHC B/S AA #:
PA100727800OtherTPI MEDICAID GROUP