Basic Information
| Provider Information | |||||||||
| NPI: | 1457351942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIJAYAKUMAR | ||||||||
| FirstName: | HAROHALLI | ||||||||
| MiddleName: | RAMAKRISHNAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 EAST ST | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018444500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786894601 | ||||||||
| FaxNumber: | 9786893096 | ||||||||
| Practice Location | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | 295 VARNUM AVE | ||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376235 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 71491 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 733647 | 01 | TUFT | OTHER | J09189 | 01 | MASS. BCBS | OTHER | 050034799 | 01 | RR MEDICARE | OTHER | 30005577 | 05 | NH | MEDICAID | 3053610 | 05 | MA | MEDICAID |