1801812011 NPI number — KRISTY LEE ANN CARRUTHERS PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801812011 NPI number — KRISTY LEE ANN CARRUTHERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARRUTHERS
Provider First Name:
KRISTY
Provider Middle Name:
LEE ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-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:
1801812011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 631341
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-1341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E WOOD ST
Provider Second Line Business Practice Location Address:
2ND FLOOR/RADIOLOGY
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-560-6522
Provider Business Practice Location Address Fax Number:
888-972-8644
Provider Enumeration Date:
07/14/2006

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: 363A00000X , with the licence number:  0110002023 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA1219 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00648636 . This is a "RAILROAD MEDICARE #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00754297 . This is a "RAILROAD MC ID-RSFPN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0628PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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