1457352676 NPI number — DR. CHILAKAPATI VIJAYA KUMAR MD

Table of content: MARK LANCASTER (NPI 1578383535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457352676 NPI number — DR. CHILAKAPATI VIJAYA KUMAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUMAR
Provider First Name:
CHILAKAPATI
Provider Middle Name:
VIJAYA
Provider Name Prefix Text:
DR.
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:
KUMAR
Provider Other First Name:
CHILAKAPATI
Provider Other Middle Name:
VIJAYA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1457352676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 77000 DEPT 771255
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48277-4085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-271-3000
Provider Business Mailing Address Fax Number:
313-271-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14752 NORTHLINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-285-5030
Provider Business Practice Location Address Fax Number:
734-285-8223
Provider Enumeration Date:
08/10/2005

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: 207RN0300X , with the licence number:  4301040566 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2801430 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101651 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 107216 . This is a "CARE CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 204980 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110Q26434 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4629716 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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