1528035268 NPI number — DR. KESI TABIA KINDLE-SUERSIN MD

Table of content: DR. KESI TABIA KINDLE-SUERSIN MD (NPI 1528035268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528035268 NPI number — DR. KESI TABIA KINDLE-SUERSIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINDLE-SUERSIN
Provider First Name:
KESI
Provider Middle Name:
TABIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KINDLE
Provider Other First Name:
KESI
Provider Other Middle Name:
TABIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528035268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746724
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-733-9730
Provider Business Mailing Address Fax Number:
312-733-9730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2668 PETERS CREEK PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27127-5655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-200-7020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2006

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: 207RG0300X , with the licence number:  200200933 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 804752 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13153 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7706384 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8913153 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810000708 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: D6480 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: H64259 . This is a "UHC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 10100496 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q00933 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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