1225176613 NPI number — JESSE J KRIEGER

Table of content: JESSE J KRIEGER (NPI 1225176613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225176613 NPI number — JESSE J KRIEGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRIEGER
Provider First Name:
JESSE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1225176613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZEN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58545-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-748-6383
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 1ST AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZEN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-748-6383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2007

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: 235Z00000X , with the licence number:  474 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 58563 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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