1013016864 NPI number — GRAND UNION HEALTHCARE L.L.C,

Table of content: MISS PRIYA NAYANESH SHAH DMD (NPI 1962086397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013016864 NPI number — GRAND UNION HEALTHCARE L.L.C,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND UNION HEALTHCARE L.L.C,
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:
6
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:
1013016864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74346-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-253-4500
Provider Business Mailing Address Fax Number:
918-253-6064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 EAST MONROE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74346-0409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-253-4500
Provider Business Practice Location Address Fax Number:
918-253-6064
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATHESON
Authorized Official First Name:
ORRISE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
918-253-4500

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100778240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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