1427130772 NPI number — RAYMOND L KACICH 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 1427130772 NPI number — RAYMOND L KACICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KACICH
Provider First Name:
RAYMOND
Provider Middle Name:
L
Provider Name Prefix Text:
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:
1427130772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3601 S 6TH AVE # 1-11C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85723-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-429-2580
Provider Business Mailing Address Fax Number:
520-629-4976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 S 6TH AVE # 1-11C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85723-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-429-2580
Provider Business Practice Location Address Fax Number:
520-629-4976
Provider Enumeration Date:
10/19/2006

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: 174400000X , with the licence number:  036-086191 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 036-086191 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036086191 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060021806 . This is a "RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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