1962488098 NPI number — DR. CHANDRA N PRASAD M.D.

Table of content: DR. CHANDRA N PRASAD M.D. (NPI 1962488098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962488098 NPI number — DR. CHANDRA N PRASAD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRASAD
Provider First Name:
CHANDRA
Provider Middle Name:
N
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:
1962488098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 104240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65110-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-556-7722
Provider Business Mailing Address Fax Number:
573-635-1527

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 W STADIUM BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65109-6023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-556-7722
Provider Business Practice Location Address Fax Number:
573-635-1527
Provider Enumeration Date:
12/20/2005

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: 208600000X , with the licence number:  107605 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 113361 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000015403 . This is a "LVC MCR GROUP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 290992 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 020037459 . This is a "PALMETTO GBA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 020037459 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 208198119 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD6061 . This is a "RAILROAD GROUP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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