1942257019 NPI number — KOPPOLU P SARMA MD INC

Table of content: (NPI 1942257019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942257019 NPI number — KOPPOLU P SARMA MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOPPOLU P SARMA MD INC
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:
1942257019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 6076
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-942-5745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W 61ST AVE
Provider Second Line Business Practice Location Address:
CENTER FOR IMAGING AND RADIATION
Provider Business Practice Location Address City Name:
HOBART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46342-6490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-942-5745
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SARMA
Authorized Official First Name:
KOPPOLU
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-942-5745

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  01027669A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100213740A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200008710A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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