1942394366 NPI number — SAMUEL TEFERRA MD

Table of content: SAMUEL TEFERRA MD (NPI 1942394366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942394366 NPI number — SAMUEL TEFERRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEFERRA
Provider First Name:
SAMUEL
Provider Middle Name:
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:
1942394366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-266-8268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1942 E 7TH ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28204-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-384-7085
Provider Business Practice Location Address Fax Number:
704-384-7089
Provider Enumeration Date:
10/02/2006

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: 207Q00000X , with the licence number:  35-07-1841 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2018-02891 , 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: 2021663 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942394366 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196962 . This is a "ANTHEM BCBS OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 200605710A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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