Basic Information
| Provider Information | |||||||||
| NPI: | 1770680688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SETHURAMAN | ||||||||
| FirstName: | KINJAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NANAVATI | ||||||||
| OtherFirstName: | KINJAL | ||||||||
| OtherMiddleName: | ASHWIN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, MPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 64793 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
| FaxNumber: | 4103284124 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 SOUTH GREENE STREET | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
| FaxNumber: | 4103284124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M8987 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 236222 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | D68457 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 190262903 | 05 | TX | MEDICAID | 0136 | 01 | MD | BLUE CROSS | OTHER | 8AH276 | 01 | TX | BCBSTX | OTHER | 02688939 | 05 | NY | MEDICAID | 190262905 | 05 | TX | MEDICAID | 039882900 | 05 | MD | MEDICAID |