1073572434 NPI number — LARRY L KESTIN

Table of content: LARRY L KESTIN (NPI 1073572434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073572434 NPI number — LARRY L KESTIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KESTIN
Provider First Name:
LARRY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1073572434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING & RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 FULTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-2755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-338-0300
Provider Business Practice Location Address Fax Number:
248-338-0663
Provider Enumeration Date:
03/22/2006

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: 2085R0001X , with the licence number:  4301065377 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7283213 . This is a "AETNA THRU OAKLAND PHYSICIANS NETWORK SERVICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1046262 . This is a "HEALTH PLUS OF MICHIGAN THRU OAKLAND PHYSICIANS NETWORK SERVICES (OPNS)" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1073572434 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 320F362430 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7283213 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20974 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200812 . This is a "UNITED HEALTHCARE COMMUNITY PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P01013933 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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