1417094780 NPI number — SHYAM BHAKTA MD

Table of content: SHYAM BHAKTA MD (NPI 1417094780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417094780 NPI number — SHYAM BHAKTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BHAKTA
Provider First Name:
SHYAM
Provider Middle Name:
Provider Name Prefix Text:
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:
1417094780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 AMHERST RD NE STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASSILLON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44646-8518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-830-1645
Provider Business Mailing Address Fax Number:
330-834-4758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 AMHERST RD NE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASSILLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44646-8518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-830-1645
Provider Business Practice Location Address Fax Number:
330-834-4758
Provider Enumeration Date:
01/30/2007

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: 207RC0000X , with the licence number:  35089165 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 35089165 , 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: 1841239274 . This is a "PARTNERS PHYSICIAN GROUP TYPE 2 NPI #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2762498 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2551671 . This is a "PARTNERS PHYSICIAN GROUP MEDICAID GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9338635 . This is a "PARTNERS PHYSICIAN GROUP MEDICARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9691080 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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