1609080969 NPI number — GURPREET RANDHAWA MD PA

Table of content: (NPI 1609080969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609080969 NPI number — GURPREET RANDHAWA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GURPREET RANDHAWA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1609080969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 W 15TH ST
Provider Second Line Business Mailing Address:
#202
Provider Business Mailing Address City Name:
LIBERAL
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67901-2285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-626-5033
Provider Business Mailing Address Fax Number:
620-624-7881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 W 15TH ST
Provider Second Line Business Practice Location Address:
#202
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901-2285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-626-5033
Provider Business Practice Location Address Fax Number:
620-624-7881
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RANDHAWA
Authorized Official First Name:
JEIVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
620-626-5033

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0428472 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103220 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100362020B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110692 . This is a "BCBS GROUP" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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