1669660023 NPI number — GURSEWAK S. SANDHU, MD, PC

Table of content: (NPI 1669660023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669660023 NPI number — GURSEWAK S. SANDHU, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GURSEWAK S. SANDHU, MD, PC
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:
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:
1669660023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 W GROVE ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
MIDDLEBORO
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02346-1458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-947-4634
Provider Business Mailing Address Fax Number:
508-947-0635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 W GROVE ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MIDDLEBORO
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02346-1458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-947-4634
Provider Business Practice Location Address Fax Number:
508-947-0635
Provider Enumeration Date:
10/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDHU
Authorized Official First Name:
GURSEWAK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
508-947-4634

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  44829 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0109568 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GUM13473 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9722203 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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