Provider Demographics
NPI:1265600977
Name:SWAROOP N NYSHADHAM MD
Entity type:Organization
Organization Name:SWAROOP N NYSHADHAM MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-756-8190
Mailing Address - Street 1:4503 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854
Mailing Address - Country:US
Mailing Address - Phone:334-756-8190
Mailing Address - Fax:334-756-5158
Practice Address - Street 1:4503 20TH AVE
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854
Practice Address - Country:US
Practice Address - Phone:334-756-8190
Practice Address - Fax:334-756-5158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2016-02-11
Deactivation Date:2014-04-07
Deactivation Code:
Reactivation Date:2016-02-11
Provider Licenses
StateLicense IDTaxonomies
AL013121208600000X, 208D00000X
GA031483208600000X, 208D00000X
FLME49553208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000082972Medicaid
AL51082972OtherBLUE CROSS
GA000338357FMedicaid
GA300041350AMedicaid
AL51532898OtherBLUE CROSS
AL009937179OtherMCAID
AL009937179Medicaid
AL51514838OtherBLUE CROSS
AL000338357BMedicaid
GA02BDCHN01OtherMCARE
AL529928300Medicaid
C70924Medicare UPIN
AL000082972Medicaid
GA300041350AMedicaid