1447320981 NPI number — DR. MAHAMUNI GANESAN M.D.,

Table of content: DR. MAHAMUNI GANESAN M.D., (NPI 1447320981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447320981 NPI number — DR. MAHAMUNI GANESAN M.D.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANESAN
Provider First Name:
MAHAMUNI
Provider Middle Name:
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:
1447320981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 W PERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFFIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44883-2243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-448-4171
Provider Business Mailing Address Fax Number:
419-448-5551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 W PERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFFIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44883-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-448-4171
Provider Business Practice Location Address Fax Number:
419-448-5551
Provider Enumeration Date:
11/09/2006

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: 207R00000X , with the licence number:  35-034118 , 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: 0314163 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0006237 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35-034118 . This is a "OHIO STATE MEDICAL BOARD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 31-1020375-00 . This is a "WORKERS COMP.NO." identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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