1104076827 NPI number — KATHLEEN T MURRAY PHD

Table of content: KATHLEEN T MURRAY PHD (NPI 1104076827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104076827 NPI number — KATHLEEN T MURRAY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MURRAY
Provider First Name:
KATHLEEN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1104076827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
226 W MAIN ST
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
OTTUMWA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52501-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-530-7003
Provider Business Mailing Address Fax Number:
641-682-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 W MAIN ST
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
OTTUMWA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52501-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-530-7003
Provider Business Practice Location Address Fax Number:
641-682-1924
Provider Enumeration Date:
09/30/2008

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: 103TC0700X , with the licence number:  01-09P , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 001083 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1659353670 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1659353670 . This is a "BLUE CROSS BLUE SHIELD OF IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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