1265431845 NPI number — CHARLES J SUGARMAN DPM

Table of content: CHARLES J SUGARMAN DPM (NPI 1265431845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265431845 NPI number — CHARLES J SUGARMAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUGARMAN
Provider First Name:
CHARLES
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1265431845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 CHAMBER CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKESIDE PARK
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017-1686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-441-4334
Provider Business Mailing Address Fax Number:
859-441-3698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 ALEXANDRIA PIKE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41071-3290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-441-4334
Provider Business Practice Location Address Fax Number:
859-441-3698
Provider Enumeration Date:
07/18/2005

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: 213EP1101X , with the licence number:  00170 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 27-00336 . This is a "UHC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 90260191 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4491387 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 80001704 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000033161 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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