1598731275 NPI number — PETER BAMBAKIDIS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598731275 NPI number — PETER BAMBAKIDIS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BAMBAKIDIS

Provider First Name:

PETER

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1598731275

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/27/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

20525 CENTER RIDGE RD

Provider Second Line Business Mailing Address:

STE 220

Provider Business Mailing Address City Name:

ROCKY RIVER

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44116

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

440-895-5056

Provider Business Mailing Address Fax Number:

440-333-2935

Provider First Line Business Practice Location Address:

25200 CENTER RIDGE RD

Provider Second Line Business Practice Location Address:

STE 2100

Provider Business Practice Location Address City Name:

WESTLAKE

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

44145

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

440-331-4053

Provider Business Practice Location Address Fax Number:

440-331-4073

Provider Enumeration Date:

02/23/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2084N0400X , with the licence number:  35058627B , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000000246863 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
• Identifier: CA4511 . This is a "GROUP RR MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 4117752 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 0119204 . This is a "GROUP MEDICAID" identifier . This identifiers is of the category "OTHER".
• Identifier: 9273172 . This is a "GROUP MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 102920 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
• Identifier: 10788157 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
• Identifier: F58622 . This is a "SUMMACARE APEX" identifier . This identifiers is of the category "OTHER".
• Identifier: 1780634279 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
• Identifier: 341783789093 . This is a "CARESOURCE" identifier . This identifiers is of the category "OTHER".
• Identifier: 3610861 . This is a "GROUP ASC MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0501061 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 0749284 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: D3683041 . This is a "GROUP IND DIAGNOSTICS MED" identifier . This identifiers is of the category "OTHER".