1962467019 NPI number — BIG ISLAND MEDICAL, INC.

Table of content: (NPI 1962467019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962467019 NPI number — BIG ISLAND MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG ISLAND MEDICAL, INC.
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:
1962467019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81-6645 MAMALAHOA HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEALAKEKUA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96750-8190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-323-3313
Provider Business Mailing Address Fax Number:
808-322-9281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81-6645 MAMALAHOA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEALAKEKUA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96750-8190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-323-3313
Provider Business Practice Location Address Fax Number:
808-322-9281
Provider Enumeration Date:
04/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KORCZYK
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-323-3313

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  PMP431 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 571762-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000256594 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".