Basic Information
| Provider Information | |||||||||
| NPI: | 1831170083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATHAK | ||||||||
| FirstName: | SANJAY | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | 6163615828 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01056575A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200398800 | 05 | IN | MEDICAID |