1164459210 NPI number — KRISTEN S CORDERMAN PT, DPT, OCS

Table of content: KRISTEN S CORDERMAN PT, DPT, OCS (NPI 1164459210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164459210 NPI number — KRISTEN S CORDERMAN PT, DPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDERMAN
Provider First Name:
KRISTEN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, OCS
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:
1164459210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SERVAIS WAY
Provider Second Line Business Mailing Address:
ROOM 210
Provider Business Mailing Address City Name:
HURLBURT FIELD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-884-4661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SERVAIS WAY
Provider Second Line Business Practice Location Address:
ROOM 210
Provider Business Practice Location Address City Name:
HURLBURT FIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-884-4661
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

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: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT20877 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 891318800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: U4475Z . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y906W . This is a "BCBSFL GROUP #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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