Basic Information
| Provider Information | |||||||||
| NPI: | 1205871472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEKKEURUMBIL | ||||||||
| FirstName: | VIJAYA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 633819 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 NORTHCREST DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371723927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153842411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
| 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 | 208M00000X | 44167 | KY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207P00000X | 34848 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10015751 | 01 | TN | OMNICARE TENNCARE | OTHER | 64029556 | 05 | KY | MEDICAID | 3862507 | 05 | TN | MEDICAID | 3862508 | 05 | TN | MEDICAID | 3862509 | 05 | TN | MEDICAID | 4013849 | 01 | TN | BLUE CROSS | OTHER | P00384333 | 01 | TN | MEDICARE RAILROAD | OTHER | 4001211 | 01 | TN | BLUE CROSS | OTHER | 930113083 | 01 | TN | MEDICARE RAILROAD | OTHER | 21060 | 01 | TN | TLC TENNCARE | OTHER | 50004635 | 01 | KY | PASSPORT HEALTH PLAN | OTHER | P00186020 | 01 | TN | MEDICARE RAILROAD | OTHER |