1003891615 NPI number — DAVID KRUSEMARK CRNA

Table of content: DAVID KRUSEMARK CRNA (NPI 1003891615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003891615 NPI number — DAVID KRUSEMARK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUSEMARK
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1003891615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
PO BOX 800
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-8555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-8555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2005

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: 367500000X , with the licence number:  R 084231-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HP44201 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MH9041027355 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20-03452 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4K003KR , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 171208 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4K003KR . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 996066 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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