1356348346 NPI number — DR. DAMODHAR PATTABIRAMAN SURESH M.D.

Table of content: DR. DAMODHAR PATTABIRAMAN SURESH M.D. (NPI 1356348346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356348346 NPI number — DR. DAMODHAR PATTABIRAMAN SURESH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURESH
Provider First Name:
DAMODHAR
Provider Middle Name:
PATTABIRAMAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1356348346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 635283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-5283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-331-0774
Provider Business Mailing Address Fax Number:
859-578-3800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 MEDICAL VILLAGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-3439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-287-3045
Provider Business Practice Location Address Fax Number:
859-578-3800
Provider Enumeration Date:
07/05/2005

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: 207RC0000X , with the licence number:  37142 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 35-06-8603-S , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 37142 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: 01085789A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0369016 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0562616 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0969497 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64962830 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060067789 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611300608064 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2000420 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00893681 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00922859 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50024711 . This is a "PASSPORT MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0369209 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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