Provider Demographics
NPI:1821017021
Name:CHINNASAMI, BERNARD R (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:R
Last Name:CHINNASAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 QUAKER LN
Mailing Address - Street 2:STE. 207C
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3832
Mailing Address - Country:US
Mailing Address - Phone:336-883-2500
Mailing Address - Fax:
Practice Address - Street 1:302 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4324
Practice Address - Country:US
Practice Address - Phone:336-781-4080
Practice Address - Fax:336-781-4081
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35863207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC4242OtherRR GROUP
110122235OtherRR MEDICARE
NC110122235OtherRRMC INDIVIDUAL #
NC8922357Medicaid
G06030Medicare UPIN
NC8922357Medicaid
NC110122235OtherRRMC INDIVIDUAL #