1720015662 NPI number — DR. CHRISTINA MOORE KILLGOAR M.D.

Table of content: DR. PATRICK HALL OD (NPI 1558085654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720015662 NPI number — DR. CHRISTINA MOORE KILLGOAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLGOAR
Provider First Name:
CHRISTINA
Provider Middle Name:
MOORE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
CHRISTINA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720015662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 6TH AVE S
Provider Second Line Business Mailing Address:
BOX 6941
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33701-4634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-767-4429
Provider Business Mailing Address Fax Number:
727-767-4970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 6TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33701-4634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-767-4243
Provider Business Practice Location Address Fax Number:
727-767-8612
Provider Enumeration Date:
06/27/2006

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: 208000000X , with the licence number:  ME102202 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: ME102202 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 492955 . This is a "STAYWELL/HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7858470 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: N01395 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 324589 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 890134NO , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000249800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0592866 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000249800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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