1477618528 NPI number — KUNJBALA SHARMA MD

Table of content: KUNJBALA SHARMA MD (NPI 1477618528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477618528 NPI number — KUNJBALA SHARMA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARMA
Provider First Name:
KUNJBALA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHARMA
Provider Other First Name:
KUNJBALA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1477618528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 EAST AVE
Provider Second Line Business Mailing Address:
BLACKSTONE VALLEY COMMUNITY HEALTH CARE
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02860-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-722-0081
Provider Business Mailing Address Fax Number:
401-312-0318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWTUCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02860-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-722-0081
Provider Business Practice Location Address Fax Number:
401-312-0318
Provider Enumeration Date:
12/27/2006

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: 208000000X , with the licence number:  39079 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 39079 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD07897 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 400561 . This is a "BC BS OF RI (BLUECHIP)" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9765239 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 400561 . This is a "BC BS OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 961244-01 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: E05285 . This is a "BC BS OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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