1003013350 NPI number — RUPA PACHIGOLLA MD PSC

Table of content: (NPI 1003013350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003013350 NPI number — RUPA PACHIGOLLA MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUPA PACHIGOLLA MD PSC
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:
1003013350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2016 FORT WORTH HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEATHERFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76086-4706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-596-8637
Provider Business Mailing Address Fax Number:
817-599-3614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2016 FORT WORTH HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEATHERFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76086-4706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-596-8637
Provider Business Practice Location Address Fax Number:
817-599-3614
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PACHIGOLLA
Authorized Official First Name:
RUPA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
817-596-8637

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N0337 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00Z738 . This is a "MEDICARE GROUP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 197261401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D1093868 . This is a "CLIA #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1639165731 . This is a "MCRE INDV NPI #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 38179 . This is a "LICENSE NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1003013350 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: N0337 . This is a "TEXAS LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 197259801 . This is a "MEDICAID GRP #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 64071715 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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