1811976327 NPI number — DR. KAILAS D DAVE MD FAAP

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 1811976327 NPI number — DR. KAILAS D DAVE MD FAAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVE
Provider First Name:
KAILAS
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FAAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVE
Provider Other First Name:
KAILAS
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811976327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLETON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18201-0603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-436-1635
Provider Business Mailing Address Fax Number:
570-436-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 GOSHEN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-0603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-436-1635
Provider Business Practice Location Address Fax Number:
570-434-1635
Provider Enumeration Date:
01/12/2006

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:  MD044209L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0012719660004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138534 . This is a "MED PLUS UNISON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001393 . This is a "FIRST PRIORITY HEALTH" identifier . This identifiers is of the category "OTHER".




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