1316932601 NPI number — DR. MARVIN RENELL KYM MD

Table of content: DR. MARVIN RENELL KYM MD (NPI 1316932601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316932601 NPI number — DR. MARVIN RENELL KYM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KYM
Provider First Name:
MARVIN
Provider Middle Name:
RENELL
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:
1316932601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-882-4511
Provider Business Mailing Address Fax Number:
208-883-6580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 W A ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-4042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-1135
Provider Business Practice Location Address Fax Number:
208-892-0174
Provider Enumeration Date:
09/13/2005

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: 207X00000X , with the licence number:  WA0029535 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: M6029 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10298 . This is a "BCI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 003782400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010003567 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8138554 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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