1013167303 NPI number — BHAVANI PEDDAGOVINDU MD

Table of content: BHAVANI PEDDAGOVINDU MD (NPI 1013167303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013167303 NPI number — BHAVANI PEDDAGOVINDU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDDAGOVINDU
Provider First Name:
BHAVANI
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:
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:
1013167303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 WOODLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-267-5151
Provider Business Mailing Address Fax Number:
541-266-4572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 WOODLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-267-5151
Provider Business Practice Location Address Fax Number:
541-266-4572
Provider Enumeration Date:
09/24/2008

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: 207R00000X , with the licence number:  MD158124 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0300X , with the licence number: MD158124 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P01278284 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 161133 . This is a "NBMC GROUP MEDICAID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1407812365 . This is a "NBMC GROUP NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 930635514 . This is a "NBMC GROUP TAX ID FOR BILLING" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500648004 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R0000WFBTV . This is a "NBMC-GROUP MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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