1891757100 NPI number — SUBHASH C GUPTA MD

Table of content: SUBHASH C GUPTA MD (NPI 1891757100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891757100 NPI number — SUBHASH C GUPTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUPTA
Provider First Name:
SUBHASH
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1891757100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1540 LAKE LANSING RD
Provider Second Line Business Mailing Address:
SUITE G06
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48912-3756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-482-7246
Provider Business Mailing Address Fax Number:
517-484-7377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 E MICHIGAN AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-364-5330
Provider Business Practice Location Address Fax Number:
517-364-5335
Provider Enumeration Date:
04/03/2006

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: 207L00000X , with the licence number:  4301056151 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 4301056151 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 4301056151 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 4301056151 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3151420 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2919074 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2702808 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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