1215958459 NPI number — PRAVEEN ROY MD

Table of content: PRAVEEN ROY MD (NPI 1215958459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215958459 NPI number — PRAVEEN ROY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROY
Provider First Name:
PRAVEEN
Provider Middle Name:
Provider Name Prefix Text:
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:
1215958459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2841 DEBARR RD STE 50
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-2945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-276-2811
Provider Business Mailing Address Fax Number:
907-276-2810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2841 DEBARR RD STE 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-2945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-276-2811
Provider Business Practice Location Address Fax Number:
907-276-2810
Provider Enumeration Date:
07/22/2006

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: 207RG0100X , with the licence number:  2006017171 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MD.203593 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 55751 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00342850 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 209956 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 201151206 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2110187 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00531049 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 753815 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00420900 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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