1942358221 NPI number — KENDEL THIRLBENNY PA-C

Table of content: KENDEL THIRLBENNY PA-C (NPI 1942358221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942358221 NPI number — KENDEL THIRLBENNY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIRLBENNY
Provider First Name:
KENDEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1942358221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 OCEANGATE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90802-4302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-499-6191
Provider Business Mailing Address Fax Number:
877-469-3649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 E ARTESIA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90805-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-423-3383
Provider Business Practice Location Address Fax Number:
877-469-3649
Provider Enumeration Date:
01/05/2007

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: 363AM0700X , with the licence number:  PA 16098 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: EFF: 1/18/2013 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA16098 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01272662/DU4032 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P01273082 . This is a "RAILROAD MEDICARE-DU4032-WILMINGTON" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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