1578500955 NPI number — SAMSON G VIMALANANDA MD

Table of content: SAMSON G VIMALANANDA MD (NPI 1578500955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578500955 NPI number — SAMSON G VIMALANANDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIMALANANDA
Provider First Name:
SAMSON
Provider Middle Name:
G
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:
1578500955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 SISTER PIERRE DR
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
21204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-827-6408
Provider Business Mailing Address Fax Number:
443-279-0537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 ROUTE 88 FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08724-3018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-295-6543
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2006

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: 2084P0800X , with the licence number:  D20273 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 25MA10657200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 461905000 . This is a "MAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: PVPB76641 . This is a "APS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0019 . This is a "BSDC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 595882 . This is a "MAMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 096890 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1023561 . This is a "CIGN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 253557 . This is a "COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 150N131G . This is a "MBMD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 221073 . This is a "KAIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42225312 . This is a "BSMD" identifier . This identifiers is of the category "OTHER".




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