1770524035 NPI number — KEVIN L WALTERS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770524035 NPI number — KEVIN L WALTERS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WALTERS

Provider First Name:

KEVIN

Provider Middle Name:

L

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1770524035

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/22/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

415 JEFFERSON ST NORTH

Provider Second Line Business Mailing Address:

TRI-COUNTY HOSPITAL

Provider Business Mailing Address City Name:

WADENA

Provider Business Mailing Address State Name:

MN

Provider Business Mailing Address Postal Code:

56482-1296

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

218-631-3510

Provider Business Mailing Address Fax Number:

218-631-7587

Provider First Line Business Practice Location Address:

4 DEERWOOD AVE NW

Provider Second Line Business Practice Location Address:

TRI-COUNTY HEALTH CARE WADENA CLINIC

Provider Business Practice Location Address City Name:

WADENA

Provider Business Practice Location Address State Name:

MN

Provider Business Practice Location Address Postal Code:

56482-1296

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

218-631-1360

Provider Business Practice Location Address Fax Number:

218-631-7507

Provider Enumeration Date:

06/09/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  37842 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: MN100008 . This is a "LHS/BANNERHEALTH #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 768832 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 890222400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: DA9041015691 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP19560 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0106027 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0106028 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 13136 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 142299 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0106020 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 21526 . This is a "SIOUX VALLEY #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".