Provider Demographics
NPI:1861533507
Name:TRUMBULL INTERNAL MEDICINE INC.
Entity type:Organization
Organization Name:TRUMBULL INTERNAL MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBHASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATERPAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-856-8148
Mailing Address - Street 1:628 NILES CORTLAND RD SE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2473
Mailing Address - Country:US
Mailing Address - Phone:330-856-8148
Mailing Address - Fax:330-856-8159
Practice Address - Street 1:628 NILES CORTLAND RD SE
Practice Address - Street 2:SUITE # 102
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2473
Practice Address - Country:US
Practice Address - Phone:330-856-8148
Practice Address - Fax:330-856-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069121K207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
593088331009OtherHOWLAND
J69121OtherHEWHNFALLS SYMMECARE
331664OtherHEALTH ASSURANCE
000000379459OtherANTHEM
OH0197353Medicaid
5583069OtherAETNA
92344OtherQUALCHOICE
593088331008OtherMEDICAL MUTUAL
5583069OtherAETNA
331664OtherHEALTH ASSURANCE
E15273Medicare UPIN