1073500765 NPI number — DR. HARISH MARISIDDAIAH M.D.

Table of content: DR. HARISH MARISIDDAIAH M.D. (NPI 1073500765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073500765 NPI number — DR. HARISH MARISIDDAIAH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARISIDDAIAH
Provider First Name:
HARISH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1073500765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2240 REMOUNT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28054-4725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-671-5311
Provider Business Mailing Address Fax Number:
704-671-5308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 X RAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-7491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-834-2465
Provider Business Practice Location Address Fax Number:
704-834-2466
Provider Enumeration Date:
09/29/2005

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: 207RI0200X , with the licence number:  MD61064980 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0200X , with the licence number: 9500993 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: N00993 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8954784 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".