1801984844 NPI number — MYRON K KRUEGER MD PA

Table of content: (NPI 1801984844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801984844 NPI number — MYRON K KRUEGER MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYRON K KRUEGER MD PA
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:
1801984844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/13/2007
NPI Reactivation Date:
11/09/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
331 MAINE STREET
Provider Second Line Business Mailing Address:
SUITE 24
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-729-0161
Provider Business Mailing Address Fax Number:
207-721-9199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 MAINE STREET
Provider Second Line Business Practice Location Address:
SUITE 24
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-729-0161
Provider Business Practice Location Address Fax Number:
207-721-9199
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRUEGER
Authorized Official First Name:
MYRON
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-729-0161

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  6319 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1041452 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0018296 . This is a "ANTHEM BCBS OF ME" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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