1760869754 NPI number — BALRAJ S BAJAJ M.D

Table of content: BALRAJ S BAJAJ M.D (NPI 1760869754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760869754 NPI number — BALRAJ S BAJAJ M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAJAJ
Provider First Name:
BALRAJ
Provider Middle Name:
S
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:
1760869754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT. 453 PO BOX 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38148-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7605 FOREST AVENUE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23229-4936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-285-4025
Provider Business Practice Location Address Fax Number:
804-288-2659
Provider Enumeration Date:
04/29/2015

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: 207K00000X , with the licence number:  0101267271 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VAC617A . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1760869754 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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