1770757791 NPI number — DAVID A. KYLE OD PC

Table of content: (NPI 1770757791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770757791 NPI number — DAVID A. KYLE OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID A. KYLE OD PC
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:
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:
1770757791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 W BARAGA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-4068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-228-8808
Provider Business Mailing Address Fax Number:
906-228-9022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 W BARAGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-228-8808
Provider Business Practice Location Address Fax Number:
906-228-9022
Provider Enumeration Date:
04/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KYLE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
906-228-8808

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003683 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 4901003683 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WP0200X , with the licence number: 4901003683 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WS0006X , with the licence number: 4901003683 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 130001809 . This is a "WEA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900E265210 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 94-3319568 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".