1376658948 NPI number — KHOZEMA RAJKOTWALA MD INC

Table of content: (NPI 1376658948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376658948 NPI number — KHOZEMA RAJKOTWALA MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KHOZEMA RAJKOTWALA MD INC
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:
PRIMARY FAMILY HEALTHCARE
Provider Other Organization Name Type Code:
3
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:
1376658948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
990 SOUTH PROSPECT STREET
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-375-0775
Provider Business Mailing Address Fax Number:
740-375-0774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 SOUTH PROSPECT STREET
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-375-0775
Provider Business Practice Location Address Fax Number:
740-375-0774
Provider Enumeration Date:
08/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAJKOTWALA
Authorized Official First Name:
KHOZEMA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD SELFEMPLOYED
Authorized Official Telephone Number:
740-375-0775

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  350677778 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110183567 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000141025 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0176321 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0404230 . This is a "UHC" identifier . This identifiers is of the category "OTHER".