1033117817 NPI number — DR. RAJESH BOORGU M.D.

Table of content: DR. RAJESH BOORGU M.D. (NPI 1033117817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033117817 NPI number — DR. RAJESH BOORGU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOORGU
Provider First Name:
RAJESH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033117817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
422 E DR HICKS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35630-5763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-766-1401
Provider Business Mailing Address Fax Number:
256-766-1402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
422 E DR HICKS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35630-5763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-766-1401
Provider Business Practice Location Address Fax Number:
256-766-1402
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  000020221 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 000020221 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000076742 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529400760 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110208939 . This is a "MEDICARE RAILROAD/PALMETTO GBA - INDIVIDUAL" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: CC6102 . This is a "MEDICARE RAILROAD/PALMETTO GBA - GROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com