1104282409 NPI number — ERAN KESSOUS MD PC

Table of content: (NPI 1104282409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104282409 NPI number — ERAN KESSOUS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERAN KESSOUS MD PC
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:
1104282409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11120 NEW HAMPSHIRE AVE
Provider Second Line Business Mailing Address:
411
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20904-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-754-0505
Provider Business Mailing Address Fax Number:
301-754-0509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11120 NEW HAMPSHIRE AVE
Provider Second Line Business Practice Location Address:
411
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20904-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-754-0505
Provider Business Practice Location Address Fax Number:
301-754-0509
Provider Enumeration Date:
01/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOWIE
Authorized Official First Name:
DONA
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
301-754-0505

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  D0066523 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 182336 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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