Basic Information
Provider Information | |||||||||
NPI: | 1295999498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAIKUMAR | ||||||||
FirstName: | JAGANNATH | ||||||||
MiddleName: | HEREMAGALUR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 956 COURT AVE | ||||||||
Address2: | COLEMAN BLDG | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381032814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192150586 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1615 DELAWARE ST | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986322367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604142730 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2008 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
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 | MD60801533 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 50178 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | 50178 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD60801533 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 199530001 | 05 | AR |   | MEDICAID | 1533280 | 05 | TN |   | MEDICAID |