1881654085 NPI number — DR. CHANCHAMMA THANNIKKARY M.D.

Table of content: DR. CHANCHAMMA THANNIKKARY M.D. (NPI 1881654085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881654085 NPI number — DR. CHANCHAMMA THANNIKKARY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THANNIKKARY
Provider First Name:
CHANCHAMMA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1881654085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING & RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 SMITH CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE RAPIDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27870-4914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-537-1717
Provider Business Practice Location Address Fax Number:
252-537-1366
Provider Enumeration Date:
03/23/2006

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: 2085R0001X , with the licence number:  32057 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01269393 . This is a "RAILROAD MCR" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1881654085 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3722179 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5760043 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1881654085 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8982452 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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