1548490329 NPI number — DR. SAMITH THOMAS KOCHUPARAMBIL MD

Table of content: DR. SAMITH THOMAS KOCHUPARAMBIL MD (NPI 1548490329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548490329 NPI number — DR. SAMITH THOMAS KOCHUPARAMBIL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCHUPARAMBIL
Provider First Name:
SAMITH THOMAS
Provider Middle Name:
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:
K
Provider Other First Name:
SAMITH THOMAS
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548490329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 E 26TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404-4526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-884-6300
Provider Business Mailing Address Fax Number:
612-884-6363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 E 26TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-884-6300
Provider Business Practice Location Address Fax Number:
612-884-6363
Provider Enumeration Date:
07/15/2009

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: 207RH0003X , with the licence number:  55683 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 003640 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 106191 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ENROLLED , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: ENROLLED , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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