1104819556 NPI number — DR. GEORGE M KINGSLEY III DO

Table of content: DR. GEORGE M KINGSLEY III DO (NPI 1104819556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104819556 NPI number — DR. GEORGE M KINGSLEY III DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINGSLEY
Provider First Name:
GEORGE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104819556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALESTINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75801-4781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-723-8554
Provider Business Mailing Address Fax Number:
903-723-2054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALESTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75801-4781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-723-8554
Provider Business Practice Location Address Fax Number:
903-723-2054
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  34006576 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: M1837 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 176815204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176815202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176815203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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