1376530386 NPI number — DR. KENNETH K FUGATE M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376530386 NPI number — DR. KENNETH K FUGATE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUGATE
Provider First Name:
KENNETH
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1376530386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNXSUTAWNEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15767-2581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-938-7933
Provider Business Mailing Address Fax Number:
814-938-9872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUNXSUTAWNEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15767-2581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-938-7933
Provider Business Practice Location Address Fax Number:
814-938-9872
Provider Enumeration Date:
10/04/2005

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: 207R00000X , with the licence number:  MD039731L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010053900 . This is a "BLACK LUNG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 126846 . This is a "BLUE SHIELD GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 251819235 . This is a "COMMERICAL INSURANCES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P0000958 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 211751 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010556490006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003158 . This is a "BLUE SHIELD INDIVIDUAL #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 251819235001 . This is a "TRICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3733 . This is a "HEALTHEON/HEALTHAMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".