1689622714 NPI number — CHANDRASEKHAR KOTA M.D.

Table of content: CHANDRASEKHAR KOTA M.D. (NPI 1689622714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689622714 NPI number — CHANDRASEKHAR KOTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOTA
Provider First Name:
CHANDRASEKHAR
Provider Middle Name:
Provider Name Prefix Text:
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:
1689622714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-3468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-333-2001
Provider Business Mailing Address Fax Number:
814-333-6236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-337-8532
Provider Business Practice Location Address Fax Number:
814-333-1025
Provider Enumeration Date:
05/04/2006

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: 207RE0101X , with the licence number:  35.064554 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X , with the licence number: MD426736 , 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: 003359380 . This is a "HIGHMARK BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0055992 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013266190002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000736969 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000737001 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P01667340 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3810021787 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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