1679618136 NPI number — REZA A NAINI MD PA

Table of content: (NPI 1679618136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679618136 NPI number — REZA A NAINI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REZA A NAINI 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:
1679618136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 HOSPITAL RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-4019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-535-3787
Provider Business Mailing Address Fax Number:
410-257-3866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 HOSPITAL RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-4019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-535-3787
Provider Business Practice Location Address Fax Number:
410-257-3866
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NAINI
Authorized Official First Name:
REZA
Authorized Official Middle Name:
AGHAZADEH
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
410-535-3787

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 210241200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6673 . This is a "BLUE SHIELD NCA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6378RE . This is a "BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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