1912183179 NPI number — DR. TEJAS PRADEEP DESAI MD

Table of content: DR. TEJAS PRADEEP DESAI MD (NPI 1912183179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912183179 NPI number — DR. TEJAS PRADEEP DESAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESAI
Provider First Name:
TEJAS
Provider Middle Name:
PRADEEP
Provider Name Prefix Text:
DR.
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:
1912183179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 751069
Provider Second Line Business Mailing Address:
ECU PHYSICIANS: MANAGED CARE DEPARTMENT
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-744-3258
Provider Business Mailing Address Fax Number:
252-744-3194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2355 W ARLINGTON BLVD
Provider Second Line Business Practice Location Address:
ECU PHYSICIANS NEPHROLOGY
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27834-2847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-744-2545
Provider Business Practice Location Address Fax Number:
252-744-4887
Provider Enumeration Date:
01/17/2008

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: 207RN0300X , with the licence number:  2009-01070 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 235462 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 059062 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 154PN . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00789108 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5913627 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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