1154385417 NPI number — DR. KEVIN O EASLEY MD

Table of content: DR. KEVIN O EASLEY MD (NPI 1154385417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154385417 NPI number — DR. KEVIN O EASLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EASLEY
Provider First Name:
KEVIN
Provider Middle Name:
O
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1154385417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12855 NORTH FORTY DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-628-1210
Provider Business Mailing Address Fax Number:
314-628-1220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12855 NORTH FORTY DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-628-1210
Provider Business Practice Location Address Fax Number:
314-628-1220
Provider Enumeration Date:
04/13/2006

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: 207VX0201X , with the licence number:  105787 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 431787580 . This is a "GREAT WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 332932 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 431787580 . This is a "GOLDEN RULE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54920 . This is a "CMR" identifier . This identifiers is of the category "OTHER".
  • Identifier: C83613 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3605461 . This is a "MEDICARE COMPLETE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 431787580 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4915117001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 54920 . This is a "GROUP HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 207950916 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110257 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00007539 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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