1104147081 NPI number — DEEPTI BHASIN MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104147081 NPI number — DEEPTI BHASIN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEEPTI BHASIN MD 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:
1104147081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 OSIGIAN BLVD
Provider Second Line Business Mailing Address:
SUTIE 400
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31088-8988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-333-3058
Provider Business Mailing Address Fax Number:
478-333-3496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 OSIGIAN BLVD
Provider Second Line Business Practice Location Address:
SUTIE 400
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088-8988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-333-3058
Provider Business Practice Location Address Fax Number:
478-333-3496
Provider Enumeration Date:
06/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BHASIN
Authorized Official First Name:
DEEPTI
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
478-333-3058

Provider Taxonomy Codes

  • Taxonomy code: 2084F0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 408444500A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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