1922207547 NPI number — BIRENDRA KC MD

Table of content: BIRENDRA KC MD (NPI 1922207547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922207547 NPI number — BIRENDRA KC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KC
Provider First Name:
BIRENDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1922207547
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7015 A C SKINNER PKWY STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-2113
Provider Business Mailing Address Fax Number:
904-363-2606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 SAN BARTOLA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-5767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-825-4500
Provider Business Practice Location Address Fax Number:
904-825-3672
Provider Enumeration Date:
07/13/2007

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: 207R00000X , with the licence number:  2016-00813 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: ME140216 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: IVC4K . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 102868600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: LH202 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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