1255623997 NPI number — DR. VENKATA SASIDHAR MAJJIGA MD

Table of content: DR. VENKATA SASIDHAR MAJJIGA MD (NPI 1255623997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255623997 NPI number — DR. VENKATA SASIDHAR MAJJIGA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAJJIGA
Provider First Name:
VENKATA
Provider Middle Name:
SASIDHAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1255623997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19676
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62794-9676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-331-2229
Provider Business Mailing Address Fax Number:
217-757-6488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N 8TH STREET, SIU SCHOOL OF MEDICINE, PEDIATRICS
Provider Second Line Business Practice Location Address:
ROOM 3A169
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-7732
Provider Business Practice Location Address Fax Number:
217-757-6488
Provider Enumeration Date:
05/13/2011

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: 2080N0001X , with the licence number:  036.127301 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036127301 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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