Provider Demographics
NPI:1891878369
Name:JAIN, PRACHEE (MD)
Entity Type:Individual
Prefix:
First Name:PRACHEE
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1364
Mailing Address - Country:US
Mailing Address - Phone:704-403-6260
Mailing Address - Fax:704-403-6261
Practice Address - Street 1:340 JAKE ALEXANDER BLVD W
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1364
Practice Address - Country:US
Practice Address - Phone:704-403-6260
Practice Address - Fax:704-403-6261
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89067A4Medicaid
VA010034477Medicaid
NC232008OtherMEDICARE GROUP PTAN
NC232009OtherMEDICARE GROUP PTAN
VA102872OtherANTHEM
VA102872OtherANTHEM
NC232008OtherMEDICARE GROUP PTAN
NC232009OtherMEDICARE GROUP PTAN