1619972346 NPI number — DR. TRISTAN STA.ELENA BRIONES M.D.

Table of content: DR. TRISTAN STA.ELENA BRIONES M.D. (NPI 1619972346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619972346 NPI number — DR. TRISTAN STA.ELENA BRIONES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIONES
Provider First Name:
TRISTAN
Provider Middle Name:
STA.ELENA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1619972346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 BRECKENRIDGE ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42303-0839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-926-7228
Provider Business Mailing Address Fax Number:
270-926-6559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 BRECKENRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-0839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-926-7228
Provider Business Practice Location Address Fax Number:
270-926-6559
Provider Enumeration Date:
06/17/2005

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: 2085R0001X , with the licence number:  17318 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000040652 . This is a "ANTHEM PROV.NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 260109 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50003514 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65907636 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: RO 1278131 . This is a "UMWA HEALTH & RETIREMENT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 311034844001 . This is a "BLUE SHIELD OF INDIANA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64173180 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".