1730133265 NPI number — DR. KEMPAIAH A GOWDA MD

Table of content: DR. KEMPAIAH A GOWDA MD (NPI 1730133265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730133265 NPI number — DR. KEMPAIAH A GOWDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOWDA
Provider First Name:
KEMPAIAH
Provider Middle Name:
A
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:
1730133265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15150 FORT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-282-4800
Provider Business Mailing Address Fax Number:
734-282-9302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15150 FORT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-282-4800
Provider Business Practice Location Address Fax Number:
734-282-9302
Provider Enumeration Date:
05/20/2006

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: 207RC0000X , with the licence number:  4301037654 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: 4301037652 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4301037652 . This is a "STATE LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1730133265 . This is a "BCBS TYPE 1 NPI #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0608201051 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11277306 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110007760 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301037652 . This is a "CDS #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: B43075 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0820105 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1623343 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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