1689677213 NPI number — KATHIE E BOLLENBACH M.M.S., P.A.-C

Table of content: KATHIE E BOLLENBACH M.M.S., P.A.-C (NPI 1689677213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689677213 NPI number — KATHIE E BOLLENBACH M.M.S., P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLLENBACH
Provider First Name:
KATHIE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.M.S., P.A.-C
Provider Gender Code:
F

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:
1689677213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 669
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AHOSKIE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27910-0669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-209-0237
Provider Business Mailing Address Fax Number:
252-209-0197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 NC HIGHWAY 94 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESWELL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27928-8300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-209-0237
Provider Business Practice Location Address Fax Number:
252-209-0197
Provider Enumeration Date:
05/27/2005

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: 363A00000X , with the licence number:  1233-023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1851477913 . This is a "CMH NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 390848401050 . This is a "ANTHEM" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11014110 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".