1134207269 NPI number — DR. KELLY L. IRVINE PSYD

Table of content: DR. CESAR A CALDERA M.D (NPI 1912010778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134207269 NPI number — DR. KELLY L. IRVINE PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRVINE
Provider First Name:
KELLY
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOYNIHAN
Provider Other First Name:
KELLY
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134207269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 COMMUNITY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64735-8804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-890-8156
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W NIFONG BLVD BLDG 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203-5615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-403-1071
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2006

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: 103TB0200X , with the licence number:  2018042229 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50583 . This is a "NRHSP IN PSYCH" identifier . This identifiers is of the category "OTHER".
  • Identifier: NATIONAL REGISTER # . This is a "50583" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: APA MEMBERSHIP # . This is a "69103091" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0616050 . This is a "BC/BS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 116730 . This is a "BHN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 5457314 . This is a "FIRST HEALTH/CNN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 415 . This is a "IA HSP #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 141592 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 803925 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2128566 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 228289 . This is a "ONE HEALTH & GWL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 291968 . This is a "MHN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 4142 . This is a "CPQ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 86-1043861 . This is a "MAGELAN, BIODYNE, AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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