1114938644 NPI number — DIANE MCDERMOTT KLEIST PT

Table of content: TRAVIS JAY HOLTSINGER (NPI 1063009728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114938644 NPI number — DIANE MCDERMOTT KLEIST PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEIST
Provider First Name:
DIANE
Provider Middle Name:
MCDERMOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1114938644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 COURT ST
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801-4416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-427-5370
Provider Business Mailing Address Fax Number:
603-427-5370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 COURT ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-4416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-427-5370
Provider Business Practice Location Address Fax Number:
603-427-5370
Provider Enumeration Date:
08/10/2006

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: 225100000X , with the licence number:  0920 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT379 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3533245 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0806164Y0NH02 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30392870 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2198450 . This is a "FIRST HEALTH NETWORK" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 5515310 . This is a "CCN" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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