Basic Information
| Provider Information | |||||||||
| NPI: | 1295709863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JHA | ||||||||
| FirstName: | SACHCIHIDANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 50 INDUSTRIAL PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490131246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694277937 | ||||||||
| FaxNumber: | 2694275180 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490224843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699275400 | ||||||||
| FaxNumber: | 2699275493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4010179596 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 447885410 | 05 | MI | MEDICAID | BJ8136221 | 01 | MI | DEA | OTHER |