Basic Information
Provider Information | |||||||||
NPI: | 1548490329 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOCHUPARAMBIL | ||||||||
FirstName: | SAMITH THOMAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | K | ||||||||
OtherFirstName: | SAMITH THOMAS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 910 E 26TH ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554044526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128846300 | ||||||||
FaxNumber: | 6128846363 | ||||||||
Practice Location | |||||||||
Address1: | 910 E 26TH ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554044526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128846300 | ||||||||
FaxNumber: | 6128846363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2009 | ||||||||
LastUpdateDate: | 06/09/2015 | ||||||||
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 | 207RH0003X | 55683 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 003640 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RH0003X | 106191 | MN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | ENROLLED | 05 | WI |   | MEDICAID | ENROLLED | 05 | MN |   | MEDICAID |