Provider Demographics
NPI:1437295227
Name:SANDIRA V SEGARAM MD LLC
Entity Type:Organization
Organization Name:SANDIRA V SEGARAM MD LLC
Other - Org Name:SANDIRA V. SEGARAM MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDIRA
Authorized Official - Middle Name:VAITHIA
Authorized Official - Last Name:SEGARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-813-2888
Mailing Address - Street 1:653 WILLOW GROVE ST
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-1732
Mailing Address - Country:US
Mailing Address - Phone:908-813-2888
Mailing Address - Fax:908-813-2521
Practice Address - Street 1:653 WILLOW GROVE ST
Practice Address - Street 2:SUITE 1600
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-1732
Practice Address - Country:US
Practice Address - Phone:908-813-2888
Practice Address - Fax:908-813-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05040500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1928902Medicaid
NJ115257Medicare PIN