1689967119 NPI number — JACOB B GOLDSTEIN DPM LLC

Table of content: (NPI 1689967119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689967119 NPI number — JACOB B GOLDSTEIN DPM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACOB B GOLDSTEIN DPM LLC
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:
FOOT PAIN CENTER OF KANSAS CITY
Provider Other Organization Name Type Code:
3
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:
1689967119
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230-C EAST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDNER
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66030-1643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-856-8150
Provider Business Mailing Address Fax Number:
913-856-8390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230-C EAST MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDNER
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66030-1643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-856-8150
Provider Business Practice Location Address Fax Number:
913-856-8390
Provider Enumeration Date:
05/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDSTEIN
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
913-856-8150

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  1200358KS , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 12-00358KS , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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