1073615530 NPI number — SERAPHINE A SOOSAIMANICKAM M.D.

Table of content: SERAPHINE A SOOSAIMANICKAM M.D. (NPI 1073615530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073615530 NPI number — SERAPHINE A SOOSAIMANICKAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOOSAIMANICKAM
Provider First Name:
SERAPHINE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1073615530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 E JEFFERSON ST
Provider Second Line Business Mailing Address:
KAISER PERMANENTE-MEDICARE ENROLLMENT
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-816-2424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10701 ROSEMARY DR
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE-MANASSAS
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20109-7282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-257-3000
Provider Business Practice Location Address Fax Number:
703-257-3133
Provider Enumeration Date:
09/03/2006

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: 207RG0300X , with the licence number:  25MA08030500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0101246093 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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