1639251762 NPI number — KIMBERLY A MIZACK P.A.

Table of content: KIMBERLY A MIZACK P.A. (NPI 1639251762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639251762 NPI number — KIMBERLY A MIZACK P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZACK
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1639251762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 BRAEBURN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24153-7357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-772-3530
Provider Business Mailing Address Fax Number:
540-776-2036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 BRAEBURN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24153-7357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-772-3530
Provider Business Practice Location Address Fax Number:
540-776-2036
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: 363A00000X , with the licence number:  0110002410 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639251762 . This is a "BLACK LUNG" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "INTOTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 540506332108 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "OPTIMA HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "MEDICAID QMB" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P01535314 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251761 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "HUMANA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00803340 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "ANTHEM MEDIGAP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639251762 . This is a "UMWA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".