1104823327 NPI number — DR. JAN KRISKA MD

Table of content: DR. JAN KRISKA MD (NPI 1104823327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104823327 NPI number — DR. JAN KRISKA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRISKA
Provider First Name:
JAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104823327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
708 S SOUTH ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT AIRY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27030-4589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-415-5126
Provider Business Mailing Address Fax Number:
336-415-5169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 S SOUTH ST STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT AIRY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27030-4589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-415-5126
Provider Business Practice Location Address Fax Number:
336-415-5169
Provider Enumeration Date:
07/01/2005

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: 207R00000X , with the licence number:  9701018 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: 9701018 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001011966003 . This is a "ONE HEALTH/GREAT WEST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1055X . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 110153703 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 111395 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 75844 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890155X , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142031 . This is a "SOUTHCARE PPO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1789230 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 253533 . This is a "TRIGON BCBS OF VA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 277869 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 20412 . This is a "PARTNERS MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5892546 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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