Basic Information
Provider Information | |||||||||
NPI: | 1548203839 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUREWAL | ||||||||
FirstName: | UPLEKH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1030 KINGS HWY N | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CHERRY HILL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080341907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567797774 | ||||||||
FaxNumber: | 8567790211 | ||||||||
Practice Location | |||||||||
Address1: | 9815 ROOSEVELT BLVD | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191141011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889852727 | ||||||||
FaxNumber: | 8567790211 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 10/14/2015 | ||||||||
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 | 207LP2900X | 25MA09478200 | NJ | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | MD427900 | PA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | MD427900 | PA | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0000X | 25MA09478200 | NJ | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 1015057900001 | 05 | PA |   | MEDICAID |