1134252232 NPI number — SUDHA KOLLI MD PA

Table of content: (NPI 1134252232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134252232 NPI number — SUDHA KOLLI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUDHA KOLLI MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1134252232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASKING RIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-249-2044
Provider Business Mailing Address Fax Number:
908-253-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 LIVINGSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRUNSWICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-249-2044
Provider Business Practice Location Address Fax Number:
732-249-6225
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOLLI
Authorized Official First Name:
SUDHA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
732-249-2044

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2075976001 . This is a "KEYSTONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 28658 . This is a "UNIVERSITY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01000598201 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1165329 . This is a "HORIZON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: P2212167 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2K0392 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8181705 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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