Provider Demographics
NPI:1205871472
Name:THEKKEURUMBIL, VIJAYA R (MD)
Entity type:Individual
Prefix:
First Name:VIJAYA
Middle Name:R
Last Name:THEKKEURUMBIL
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:PO BOX 633819
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:865-292-3000
Mailing Address - Fax:
Practice Address - Street 1:100 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3927
Practice Address - Country:US
Practice Address - Phone:615-384-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44167208M00000X
TN34848207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10015751OtherOMNICARE TENNCARE
KY64029556Medicaid
TN3862507Medicaid
TN3862508Medicaid
TN3862509Medicaid
TN4013849OtherBLUE CROSS
TNP00384333OtherMEDICARE RAILROAD
TN4001211OtherBLUE CROSS
TN930113083OtherMEDICARE RAILROAD
TN21060OtherTLC TENNCARE
KY50004635OtherPASSPORT HEALTH PLAN
TNP00186020OtherMEDICARE RAILROAD
TN3862507Medicaid
TN3862508Medicare PIN
TN3862507Medicare PIN