1295791598 NPI number — DR. PERIN W DIANA JR. MD

Table of content: DR. PERIN W DIANA JR. MD (NPI 1295791598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295791598 NPI number — DR. PERIN W DIANA JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIANA
Provider First Name:
PERIN
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1295791598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 MERIDEN AVE
Provider Second Line Business Mailing Address:
STE 2D
Provider Business Mailing Address City Name:
SOUTHINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06489-3235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-726-6509
Provider Business Mailing Address Fax Number:
843-726-6809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 PINE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VARNVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29944-0969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-943-5228
Provider Business Practice Location Address Fax Number:
803-943-4591
Provider Enumeration Date:
04/25/2006

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: 207W00000X , with the licence number:  20809 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP0365 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 570669239-001 . This is a "BLUE CROSS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: T49310 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 570669239-002 . This is a "BLUE CHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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