1053417212 NPI number — PENN, KANAYA, DWELLE, MD'S

Table of content: (NPI 1053417212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053417212 NPI number — PENN, KANAYA, DWELLE, MD'S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENN, KANAYA, DWELLE, MD'S
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:
PEDIATRIC GROUP OF MONTEREY
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:
1053417212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 GARDEN RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
MONTEREY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93940-5373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-372-5841
Provider Business Mailing Address Fax Number:
831-372-4820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 GARDEN RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEREY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93940-5334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-372-5841
Provider Business Practice Location Address Fax Number:
831-372-4820
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STARK
Authorized Official First Name:
KATHIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
831-372-5841

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1053417212 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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