1093957110 NPI number — PRITI MARWAHA NUTHAKKI

Table of content: PRITI MARWAHA NUTHAKKI (NPI 1093957110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093957110 NPI number — PRITI MARWAHA NUTHAKKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUTHAKKI
Provider First Name:
PRITI
Provider Middle Name:
MARWAHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1093957110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 SIERRA DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-7241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-528-4800
Provider Business Mailing Address Fax Number:
317-865-1479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 SUPERIOR AVE STE 2700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-934-9813
Provider Business Practice Location Address Fax Number:
219-934-9823
Provider Enumeration Date:
04/03/2009

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:  036082683 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 036082683 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0008X , with the licence number: 036082683 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RT0003X , with the licence number: 01080501A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300015239 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".