1861533507 NPI number — TRUMBULL INTERNAL MEDICINE INC.

Table of content: (NPI 1861533507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861533507 NPI number — TRUMBULL INTERNAL MEDICINE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUMBULL INTERNAL MEDICINE INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1861533507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
628 NILES CORTLAND RD SE
Provider Second Line Business Mailing Address:
SUITE #102
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44484-2473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-856-8148
Provider Business Mailing Address Fax Number:
330-856-8159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 NILES CORTLAND RD SE
Provider Second Line Business Practice Location Address:
SUITE # 102
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44484-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-856-8148
Provider Business Practice Location Address Fax Number:
330-856-8159
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KHATERPAUL
Authorized Official First Name:
SUBHASH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT DENTIST
Authorized Official Telephone Number:
330-856-8148

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35069121K , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 593088331009 . This is a "HOWLAND" identifier . This identifiers is of the category "OTHER".
  • Identifier: J69121 . This is a "HEWHNFALLS SYMMECARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 331664 . This is a "HEALTH ASSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000379459 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0197353 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5583069 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 92344 . This is a "QUALCHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 593088331008 . This is a "MEDICAL MUTUAL" identifier . This identifiers is of the category "OTHER".




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