1053310540 NPI number — SEJAL A THAKER M.D.

Table of content: SEJAL A THAKER M.D. (NPI 1053310540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053310540 NPI number — SEJAL A THAKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THAKER
Provider First Name:
SEJAL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1053310540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3231 EUCLID AVE
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
BERWYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60402-3471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-783-2644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3231 EUCLID AVE
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-3471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-783-2644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2005

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: 207RP1001X , with the licence number:  036123694 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0200X , with the licence number: 036123694 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 202143 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3238831 . This is a "CIGNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 412690 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050483739 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 29951-4 . This is a "BCBS OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 7057835 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA41888 . This is a "HARVARD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 478831 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 036123694 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 709003710 . This is a "MEDICARE GROUP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 31388 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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