1629281530 NPI number — MR. MICHAEL CASHMAN KELLY MS - LP

Table of content: MR. MICHAEL CASHMAN KELLY MS - LP (NPI 1629281530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629281530 NPI number — MR. MICHAEL CASHMAN KELLY MS - LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
MICHAEL
Provider Middle Name:
CASHMAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS - LP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
PATRICK
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NONE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629281530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 W SAINT GERMAIN ST APT 256
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56301-4639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-230-0191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 STEARNS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-4491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-229-1500
Provider Business Practice Location Address Fax Number:
320-229-1505
Provider Enumeration Date:
05/07/2007

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: 103TB0200X , with the licence number:  LP 4136 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 517402 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62 - 64674 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 00189405 . This is a "EMPLOYEE ID FOR STATE OF" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 422T6KE . This is a "BLUE CROSS- BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 00189405 . This is a "MN EMPLOYEE ID NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 13H51876KE . This is a "B.H.S.I." identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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