1104880392 NPI number — DR. MARIAMMA CHELAGIRI MD

Table of content: DR. MARIAMMA CHELAGIRI MD (NPI 1104880392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104880392 NPI number — DR. MARIAMMA CHELAGIRI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHELAGIRI
Provider First Name:
MARIAMMA
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
GEORGE
Provider Other First Name:
MARIAMMA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104880392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
STONY BROOK WTC WELLNESS PROGRAM,
Provider Second Line Business Mailing Address:
500 COMMACK ROAD, SUITE 204
Provider Business Mailing Address City Name:
COMMACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11725-5022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-855-1200
Provider Business Mailing Address Fax Number:
631-630-6297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 COMMACK RD UNIT 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMACK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11725-5022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-855-1200
Provider Business Practice Location Address Fax Number:
631-630-6297
Provider Enumeration Date:
04/14/2006

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: 207R00000X , with the licence number:  234125 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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