=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225258049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSHIL K MEHROTRA MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 JACOB ST STE 302
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-232-1122
-----------------------------------------------------
Fax | 304-234-1873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 JACOB ST STE 302
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-232-1122
-----------------------------------------------------
Fax | 304-234-1873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SUSHIL KUMAR MEHROTRA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-232-1122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------