1740264035 NPI number — SADEKA TAMANNA M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740264035 NPI number — SADEKA TAMANNA M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

TAMANNA

Provider First Name:

SADEKA

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

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:

1740264035

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/09/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1500 E WOODROW WILSON AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

JACKSON

Provider Business Mailing Address State Name:

MS

Provider Business Mailing Address Postal Code:

39216-5116

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

601-362-4471

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1500 E WOODROW WILSON AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

JACKSON

Provider Business Practice Location Address State Name:

MS

Provider Business Practice Location Address Postal Code:

39216-5116

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

601-362-4471

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

12/01/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  46125 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: 20279 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: HP39742 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
• Identifier: 04-06054 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 131014 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 565333 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 06325569 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 155L1TA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 1907895 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 155L1TA . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 8586 . This is a "AVERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 916487100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 155L1TA . This is a "BCBS/MEDICARE SUPPLEMENT" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: MH9041035331 . This is a "PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".