1053602235 NPI number — SUMA CHANDRA KANNABIRAN MD

Table of content: MICKYAS YOHANNES TEKELE (NPI 1427652031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053602235 NPI number — SUMA CHANDRA KANNABIRAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANNABIRAN
Provider First Name:
SUMA
Provider Middle Name:
CHANDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHANDRA
Provider Other First Name:
SUMA
Provider Other Middle Name:
KANAKALALITA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053602235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-5348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-225-8885
Provider Business Mailing Address Fax Number:
508-334-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 LAKE AVENUE NORTH
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-334-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2011

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: 2085R0202X , with the licence number: 279413 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110134748A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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