1285627778 NPI number — DR. STEPHEN E KILLIAN MD

Table of content: DR. STEPHEN E KILLIAN MD (NPI 1285627778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285627778 NPI number — DR. STEPHEN E KILLIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLIAN
Provider First Name:
STEPHEN
Provider Middle Name:
E
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:
1285627778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6480
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3169 BRAVERTON ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21037-2679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-956-4911
Provider Business Practice Location Address Fax Number:
410-956-4935
Provider Enumeration Date:
08/30/2005

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: 207Q00000X , with the licence number:  D0029193 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2108711 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32789009 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3418811100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5854249 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145724700 . This is a "FEDERAL WORKMANS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 813341 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9958 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".




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