1215972195 NPI number — DR. SANDRA V HAZRA MD

Table of content: DR. SANDRA V HAZRA MD (NPI 1215972195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215972195 NPI number — DR. SANDRA V HAZRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAZRA
Provider First Name:
SANDRA
Provider Middle Name:
V
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:
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:
1215972195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24701 EUCLID AVE
Provider Second Line Business Mailing Address:
THIRD FLOOR BILLING SERVICES
Provider Business Mailing Address City Name:
EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44117-1714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-844-3951
Provider Business Mailing Address Fax Number:
440-722-8396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5133 RIDGE RD STE 5
Provider Second Line Business Practice Location Address:
SEIDMAN CANCER CTR
Provider Business Practice Location Address City Name:
WADSWORTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44281-8078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-844-3951
Provider Business Practice Location Address Fax Number:
440-722-8396
Provider Enumeration Date:
06/17/2006

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: 207RH0003X , with the licence number:  MD175021 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 35044095 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0423581 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 341660197A . This is a "SUMMACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000134345 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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