1164418075 NPI number — DR. SUKUMAR PUVVALA MD

Table of content: DR. SUKUMAR PUVVALA MD (NPI 1164418075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164418075 NPI number — DR. SUKUMAR PUVVALA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUVVALA
Provider First Name:
SUKUMAR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164418075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-812-4083
Provider Business Mailing Address Fax Number:
717-812-2244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MONUMENT RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-5074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-812-4083
Provider Business Practice Location Address Fax Number:
717-812-2244
Provider Enumeration Date:
09/26/2005

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: 2085R0202X , with the licence number:  MD421519 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001958935 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 402022700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7581465 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50074893 . This is a "CAPITAL BLUE CROSS WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 919374 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 235944 . This is a "UNISON-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1468864 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1530454 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2006917 . This is a "AMERIHEALTH MERCY WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 212042 . This is a "JOHN HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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