1487662003 NPI number — DR. SUMIT KUMAR GUPTA MD

Table of content: MRS. JENEE ASHLEY DOUGLAS (NPI 1093235749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487662003 NPI number — DR. SUMIT KUMAR GUPTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
SUMIT
Provider Middle Name:
KUMAR
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:
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:
1487662003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 FAIRVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-295-3000
Provider Business Mailing Address Fax Number:
704-295-3506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 W ARBORS DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-295-3500
Provider Business Practice Location Address Fax Number:
704-295-3506
Provider Enumeration Date:
08/03/2006

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: 207W00000X , with the licence number:  SG075835 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 2008-01681 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1502C . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 180G410170 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20096148 . This is a "SELECT HEALTH OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 2687 . This is a "EVOLUTIONS HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5910409 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7719573 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: N01682 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104779114 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89695 . This is a "CHCARES OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 01224936 . This is a "AMERIGROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00667584 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SG075835 . This is a "MED LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 000000291982 . This is a "UNISON HEALTH PLAN OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 773424 . This is a "WELLCARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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