1053388777 NPI number — TAHIRA SAIFUDDIN MD

Table of content: TAHIRA SAIFUDDIN MD (NPI 1053388777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053388777 NPI number — TAHIRA SAIFUDDIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAIFUDDIN
Provider First Name:
TAHIRA
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:
1053388777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11035 W SYCAMORE HILLS DR STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46814-9310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-241-1233
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 BROADWAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-3985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-907-3550
Provider Business Practice Location Address Fax Number:
207-907-3562
Provider Enumeration Date:
03/01/2006

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: 207RG0100X , with the licence number:  01061185A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 01061185 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MD23200 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2649567 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000672226 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00286425 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000382926 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00878854 . This is a "MEDICARE RR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200800540 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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