1407142474 NPI number — SOMBABU N MAGANTI M.D

Table of content: SOMBABU N MAGANTI M.D (NPI 1407142474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407142474 NPI number — SOMBABU N MAGANTI M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAGANTI
Provider First Name:
SOMBABU
Provider Middle Name:
N
Provider Name Prefix Text:
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:
1407142474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65801-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 S FREMONT AVE
Provider Second Line Business Practice Location Address:
STE 3000
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-3911
Provider Business Practice Location Address Fax Number:
417-820-3924
Provider Enumeration Date:
06/28/2011

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: 2084N0400X , with the licence number:  2011022935 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0600X , with the licence number: 25MA08817500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00990413 . This is a "RR MCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 188731001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1407142474 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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