1265600977 NPI number — SWAROOP N NYSHADHAM MD

Table of content: (NPI 1265600977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265600977 NPI number — SWAROOP N NYSHADHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWAROOP N NYSHADHAM MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1265600977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/07/2014
NPI Reactivation Date:
02/11/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4503 20TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-756-8190
Provider Business Mailing Address Fax Number:
334-756-5158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4503 20TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-756-8190
Provider Business Practice Location Address Fax Number:
334-756-5158
Provider Enumeration Date:
02/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
334-756-8190

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  013121 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 031483 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: ME49553 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 013121 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X , with the licence number: 031483 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: ME49553 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000082972 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51082972 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000338357F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300041350A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51532898 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009937179 . This is a "MCAID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009937179 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51514838 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000338357B , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02BDCHN01 . This is a "MCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 529928300 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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