1558569665 NPI number — KIM BURDICK WHCNP

Table of content: KIM BURDICK WHCNP (NPI 1558569665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558569665 NPI number — KIM BURDICK WHCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDICK
Provider First Name:
KIM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
WHCNP
Provider Gender Code:
F

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:
1558569665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 W COLORADO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75208-2382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-947-6700
Provider Business Mailing Address Fax Number:
214-947-6701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 W COLORADO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75208-2382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-947-6700
Provider Business Practice Location Address Fax Number:
214-947-6701
Provider Enumeration Date:
07/10/2007

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: 363LW0102X , with the licence number:  AP109765 , 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: 042494704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494708 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494707 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494709 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494711 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494706 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042494710 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y2093 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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