1346445624 NPI number — PREMA R MENON MD

Table of content: PREMA R MENON MD (NPI 1346445624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346445624 NPI number — PREMA R MENON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENON
Provider First Name:
PREMA
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1346445624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
89 BEAUMONT AVE
Provider Second Line Business Mailing Address:
GIVEN D208D
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05405-1742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-656-3525
Provider Business Mailing Address Fax Number:
802-656-3526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
PULMONARY AND CRITICAL CARE DIVISION FAHC
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05405-3421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-1558
Provider Business Practice Location Address Fax Number:
802-847-2444
Provider Enumeration Date:
06/18/2007

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: 207RP1001X , with the licence number:  0420012263 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200872260A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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