1447257316 NPI number — ERIC A KIVISTO DO

Table of content: ERIC A KIVISTO DO (NPI 1447257316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447257316 NPI number — ERIC A KIVISTO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIVISTO
Provider First Name:
ERIC
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1447257316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 E 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61342-9216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-539-1789
Provider Business Mailing Address Fax Number:
815-539-1430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 E 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
MENDOTA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61342-9010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-539-1789
Provider Business Practice Location Address Fax Number:
815-539-1430
Provider Enumeration Date:
07/06/2005

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: 208600000X , with the licence number:  5101011210 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 036091073 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 371342699 . This is a "FEIN NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036091073 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02706617 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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