1114005501 NPI number — KRISTINA JEAN POLLER D.O

Table of content: KRISTINA JEAN POLLER D.O (NPI 1114005501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114005501 NPI number — KRISTINA JEAN POLLER D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLER
Provider First Name:
KRISTINA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIDDLE
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114005501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 E JEFFERSON ST
Provider Second Line Business Mailing Address:
KAISER PERMANENTE MEDICARE ENROLLMENT
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-4908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-816-2424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8008 WESTPARK DR
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER
Provider Business Practice Location Address City Name:
MC LEAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22102-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-287-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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: 207L00000X , with the licence number:  H0069445 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 0102202776 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 418033000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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