1104034164 NPI number — DR. KEVIN M STANCOVEN D.O.

Table of content: DR. KEVIN M STANCOVEN D.O. (NPI 1104034164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104034164 NPI number — DR. KEVIN M STANCOVEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANCOVEN
Provider First Name:
KEVIN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1104034164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2386
Provider Second Line Business Mailing Address:
BRAZOS VALLEY PATHOLOGY
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-489-0201
Provider Business Mailing Address Fax Number:
512-597-2713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 SETON PARKWAY
Provider Second Line Business Practice Location Address:
SETON MEDICAL CENTER WILLIAMSON
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-814-0298
Provider Business Practice Location Address Fax Number:
512-597-2713
Provider Enumeration Date:
05/21/2007

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: 207ZC0500X , with the licence number:  N5415 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: N5415 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2866683 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TXB132498 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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