1639229008 NPI number — KAILUA DERMATOLOGY & ASSOCIATES LTD

Table of content: (NPI 1639229008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639229008 NPI number — KAILUA DERMATOLOGY & ASSOCIATES LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAILUA DERMATOLOGY & ASSOCIATES LTD
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:
1639229008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 AULIKE ST
Provider Second Line Business Mailing Address:
SUITE 311
Provider Business Mailing Address City Name:
KAILUA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96734-2758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-261-6133
Provider Business Mailing Address Fax Number:
808-262-9222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 AULIKE ST
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
KAILUA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96734-2758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-261-6133
Provider Business Practice Location Address Fax Number:
808-262-9222
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HELLREICH
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-261-6133

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  2088 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: X34632 . This is a "HMSA BCBS" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 03119501 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191661 . This is a "HIEL" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: A3463 5 . This is a "HMSA HMO KANEOHE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: MD2088 . This is a "QHCP MDX" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: MD2088 02 . This is a "QHCP MDX" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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