Provider Demographics
NPI:1548701295
Name:SULE, KEDAR ARUN
Entity type:Individual
Prefix:
First Name:KEDAR
Middle Name:ARUN
Last Name:SULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2664
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:1600 CRAIN HWY S STE 302
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6445
Practice Address - Country:US
Practice Address - Phone:410-768-1213
Practice Address - Fax:410-768-1203
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037675225100000X
MD26396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6549860Medicaid