1275732174 NPI number — DR. SIVA P BELLAM M.D

Table of content: DR. SIVA P BELLAM M.D (NPI 1275732174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275732174 NPI number — DR. SIVA P BELLAM M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BELLAM
Provider First Name:
SIVA
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1275732174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 SE HILLMOOR DR
Provider Second Line Business Mailing Address:
STE 306
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-7539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-398-6016
Provider Business Mailing Address Fax Number:
772-337-0320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 SE HILLMOOR DR
Provider Second Line Business Practice Location Address:
STE 306
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-7539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-398-6016
Provider Business Practice Location Address Fax Number:
772-337-0320
Provider Enumeration Date:
07/12/2007

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:  ME70221 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31481 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 830005561 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 250467700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2967902005 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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