1891775862 NPI number — STEPHEN B KAISER PT

Table of content: STEPHEN B KAISER PT (NPI 1891775862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891775862 NPI number — STEPHEN B KAISER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAISER
Provider First Name:
STEPHEN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1891775862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1909 VISTA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-745-8851
Provider Business Mailing Address Fax Number:
307-742-0961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 VISTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-745-8851
Provider Business Practice Location Address Fax Number:
307-742-0961
Provider Enumeration Date:
01/18/2006

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: 225100000X , with the licence number:  PT1110 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 313301 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00223517 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 120528500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".