1912014606 NPI number — GAVINI MEDICAL GROUP,LTD

Table of content: (NPI 1912014606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912014606 NPI number — GAVINI MEDICAL GROUP,LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAVINI MEDICAL GROUP,LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912014606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10000 WATSON RD
Provider Second Line Business Mailing Address:
2L-24
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63126-1854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-822-7033
Provider Business Mailing Address Fax Number:
314-822-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 WATSON RD
Provider Second Line Business Practice Location Address:
2L-24
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63126-1854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-822-7033
Provider Business Practice Location Address Fax Number:
314-822-3666
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAWKINS
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
ANNETTE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
314-822-7033

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  R6940 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 997 . This is a "FEDERAL BC/BS OF MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 011155588 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 501758304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17766 . This is a "BC/BS SHIELD OF MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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