1770680688 NPI number — KINJAL SETHURAMAN MD,

Table of content: KINJAL SETHURAMAN MD, (NPI 1770680688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770680688 NPI number — KINJAL SETHURAMAN MD,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SETHURAMAN
Provider First Name:
KINJAL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD,
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NANAVATI
Provider Other First Name:
KINJAL
Provider Other Middle Name:
ASHWIN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, MPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770680688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64793
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-328-6704
Provider Business Mailing Address Fax Number:
410-328-4124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 SOUTH GREENE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-6704
Provider Business Practice Location Address Fax Number:
410-328-4124
Provider Enumeration Date:
09/20/2006

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: 207P00000X , with the licence number:  M8987 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 236222 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: D68457 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 190262903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0136 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 8AH276 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 02688939 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190262905 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 039882900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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