1730241159 NPI number — THOMAS J NEDUMTHOTTATHIL M.D.

Table of content: THOMAS J NEDUMTHOTTATHIL M.D. (NPI 1730241159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730241159 NPI number — THOMAS J NEDUMTHOTTATHIL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEDUMTHOTTATHIL
Provider First Name:
THOMAS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1730241159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 AIRPORT BUSINESS PARK DR
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37160-7446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-685-8620
Provider Business Mailing Address Fax Number:
931-685-8621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 AIRPORT BUSINESS PARK DR
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37160-7446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-685-8620
Provider Business Practice Location Address Fax Number:
931-685-8621
Provider Enumeration Date:
12/14/2006

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: 207R00000X , with the licence number:  42606 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 25MA08034600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4163983 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4239941 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 42635 . This is a "MEDICAID TLC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1507217 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1516785 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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