1932158136 NPI number — THARACKANDATHIL OORAN SHANAVAS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932158136 NPI number — THARACKANDATHIL OORAN SHANAVAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANAVAS
Provider First Name:
THARACKANDATHIL
Provider Middle Name:
OORAN
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:
1932158136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 KIMOLE LN
Provider Second Line Business Mailing Address:
SUITE B-1
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-1491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-263-6733
Provider Business Mailing Address Fax Number:
517-263-7148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 KIMOLE LN
Provider Second Line Business Practice Location Address:
SUITE B-1
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-1491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-263-6733
Provider Business Practice Location Address Fax Number:
517-263-7148
Provider Enumeration Date:
05/08/2006

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: 208000000X , with the licence number:  TS034422 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350D676100 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 18632 . This is a "HEALTH PLAN OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5450691 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 03744 . This is a "PARAMOUNT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1099349 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115715 . This is a "CARE CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 119775 . This is a "GREAT LAKES OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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