1649476755 NPI number — ROBERT W. KUNKLE MD, INC PS

Table of content: (NPI 1649476755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649476755 NPI number — ROBERT W. KUNKLE MD, INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT W. KUNKLE MD, INC PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1649476755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
439 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOX ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98333-9715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-853-3100
Provider Business Mailing Address Fax Number:
253-549-2367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6712 KIMBALL DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
GIG HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98335-1212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-853-3100
Provider Business Practice Location Address Fax Number:
253-549-2367
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZIMMERMAN
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
253-514-5687

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD00028126 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1106467 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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