Basic Information
Provider Information | |||||||||
NPI: | 1740246974 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KURUVILLA | ||||||||
FirstName: | ANAND | ||||||||
MiddleName: | MATHAI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 COLONIAL BLVD | ||||||||
Address2: | ATTN: PAYER CONTRACTING & RELATIONS DEPT. | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399317342 | ||||||||
FaxNumber: | 2399317385 | ||||||||
Practice Location | |||||||||
Address1: | 600 ZEAGLER DR | ||||||||
Address2: | SUITE 2 | ||||||||
City: | PALATKA | ||||||||
State: | FL | ||||||||
PostalCode: | 321773811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3863258140 | ||||||||
FaxNumber: | 9043500032 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 05/04/2016 | ||||||||
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 | 174400000X | ME59637 | FL | N |   | Other Service Providers | Specialist |   | 2085R0001X | ME59637 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 1115823 | 01 | FL | CARE PLUS | OTHER | 12258 | 01 | FL | BCBS | OTHER | 4235259 | 01 | FL | AETNA | OTHER | P00198033 | 01 |   | MEDICARE RAILROAD | OTHER | P01451915 | 01 | FL | RR MEDICARE | OTHER | 1193327 | 01 | FL | WELLCARE | OTHER | 055904100 | 05 | FL |   | MEDICAID | 1121651 | 01 | FL | WELLCARE | OTHER | P01596516 | 01 | FL | RR MEDICARE | OTHER | 0571795 | 01 | FL | CIGNA | OTHER | 204458 | 01 | FL | AVMED | OTHER |