1255391751 NPI number — DR. KENT MICHAEL KRUG DC, MSN, FNP-BC, NPC

Table of content: DR. KENT MICHAEL KRUG DC, MSN, FNP-BC, NPC (NPI 1255391751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255391751 NPI number — DR. KENT MICHAEL KRUG DC, MSN, FNP-BC, NPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUG
Provider First Name:
KENT
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC, MSN, FNP-BC, NPC
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:
1255391751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEBER SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72543-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-362-6859
Provider Business Mailing Address Fax Number:
501-362-5735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEBER SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72543-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-362-6859
Provider Business Practice Location Address Fax Number:
501-362-5735
Provider Enumeration Date:
03/27/2006

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: 111N00000X , with the licence number:  1078 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350013492 . This is a "RAILROAD MEDICARE ID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 44-20043 . This is a "UNITED HEALTHCARE ID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 1569200004 . This is a "QUALCHOICE ID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 112917718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4212267467254300 . This is a "TRICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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