1316049604 NPI number — GARRY KIERNAN MD INC

Table of content: (NPI 1316049604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316049604 NPI number — GARRY KIERNAN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARRY KIERNAN MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1316049604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 CALISTOGA RD
Provider Second Line Business Mailing Address:
#314
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95409-3702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-539-0210
Provider Business Mailing Address Fax Number:
707-539-0210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
CARSON TAHOE REGIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89703-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-445-8795
Provider Business Practice Location Address Fax Number:
775-888-4447
Provider Enumeration Date:
09/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIERNAN
Authorized Official First Name:
GARRY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
775-267-5162

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  G50058 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: G50058 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: G50058 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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