1932267606 NPI number — DR. JERALD IVAN KUPPERBERG MD

Table of content: DR. JERALD IVAN KUPPERBERG MD (NPI 1932267606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932267606 NPI number — DR. JERALD IVAN KUPPERBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUPPERBERG
Provider First Name:
JERALD
Provider Middle Name:
IVAN
Provider Name Prefix Text:
DR.
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:
1932267606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 HOWARD HILL ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOSTER
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-397-4638
Provider Business Mailing Address Fax Number:
401-397-4638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 HOWARD HILL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOSTER
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-397-4638
Provider Business Practice Location Address Fax Number:
401-397-4638
Provider Enumeration Date:
12/05/2006

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: 208000000X , with the licence number:  MD05404 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5352215 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 406111 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8604 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1200196 . This is a "UNITED HEALTH" identifier . This identifiers is of the category "OTHER".




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