1467621110 NPI number — DR. INDRAJIT CHOUDHURI M.D.

Table of content: DR. INDRAJIT CHOUDHURI M.D. (NPI 1467621110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467621110 NPI number — DR. INDRAJIT CHOUDHURI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHOUDHURI
Provider First Name:
INDRAJIT
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:
1467621110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PHOENIXC HEALTHCARE S C
Provider Second Line Business Mailing Address:
11168 NORTH LAKE SHORE DRIVE
Provider Business Mailing Address City Name:
MEQUION
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-930-8866
Provider Business Mailing Address Fax Number:
262-287-9898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BELOIT HEALTH SYSTEM INC
Provider Second Line Business Practice Location Address:
1969 WEST HART ROAD
Provider Business Practice Location Address City Name:
BELOIT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53511-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-364-5205
Provider Business Practice Location Address Fax Number:
608-364-5593
Provider Enumeration Date:
02/27/2008

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:  51309-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 51309-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 51309-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 35129200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".