1659575132 NPI number — KATHLEEN ELIZABETH PAGE DUMITRU MD

Table of content: KATHLEEN ELIZABETH PAGE DUMITRU MD (NPI 1659575132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659575132 NPI number — KATHLEEN ELIZABETH PAGE DUMITRU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUMITRU
Provider First Name:
KATHLEEN
Provider Middle Name:
ELIZABETH PAGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAGE
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659575132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE POINTE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-4210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-797-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2007

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 37069 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017095500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".