1053555177 NPI number — DR. SANDHYA TIWADE KURIAN M.D.

Table of content: DR. SANDHYA TIWADE KURIAN M.D. (NPI 1053555177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053555177 NPI number — DR. SANDHYA TIWADE KURIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KURIAN
Provider First Name:
SANDHYA
Provider Middle Name:
TIWADE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1053555177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9556 MANCHESTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63119-1313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-961-2255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PROFESSIONAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-5068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-8574
Provider Business Practice Location Address Fax Number:
618-463-8688
Provider Enumeration Date:
04/21/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036-130438 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 207219 . This is a "PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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