1043253560 NPI number — GERALYN MARTIN CRNA

Table of content: GERALYN MARTIN CRNA (NPI 1043253560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043253560 NPI number — GERALYN MARTIN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
GERALYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1043253560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11399 170TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY FALLS
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66088-4094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4510 FREDERICK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64506-3238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-364-9992
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2006

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: 207L00000X , with the licence number:  54483 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 54483 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00455330 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 104325356000 . This is a "COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 146035 . This is a "BLUE CROSS BLUE SHIELD KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 8167 . This is a "PREFERRED HEALTH SYSTEMS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 917024705 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200536930A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39351017 . This is a "BLUE CROSS BLUE SHIELD KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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