1518943513 NPI number — AJAY BAJAJ MD

Table of content: AJAY BAJAJ MD (NPI 1518943513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518943513 NPI number — AJAY BAJAJ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAJAJ
Provider First Name:
AJAY
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:
1518943513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4901 W 79TH ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BURBANK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60459-1554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-636-0006
Provider Business Mailing Address Fax Number:
708-636-0007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 W 79TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60459-1554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-636-0006
Provider Business Practice Location Address Fax Number:
708-636-0007
Provider Enumeration Date:
12/21/2005

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: 207RG0100X , with the licence number:  036078076 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 995271 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01621679 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 995270 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036078076 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21608842 . This is a "BCBS IL" identifier . This identifiers is of the category "OTHER".




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