1063537843 NPI number — STEPHEN E KUSH P.T.

Table of content: STEPHEN E KUSH P.T. (NPI 1063537843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063537843 NPI number — STEPHEN E KUSH P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUSH
Provider First Name:
STEPHEN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1063537843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1844 E BASELINE RD
Provider Second Line Business Mailing Address:
SUITE C-5
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85283-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-833-1005
Provider Business Mailing Address Fax Number:
480-833-1312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7331 E OSBORN DR
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85251-6435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-874-4212
Provider Business Practice Location Address Fax Number:
480-874-4917
Provider Enumeration Date:
03/20/2007

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: 225100000X , with the licence number:  6496 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 0274 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 050766 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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