1265423479 NPI number — DR. KENNETH E KRZYZANIAK MD

Table of content: DR. KENNETH E KRZYZANIAK MD (NPI 1265423479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265423479 NPI number — DR. KENNETH E KRZYZANIAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRZYZANIAK
Provider First Name:
KENNETH
Provider Middle Name:
E
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:
1265423479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
MANAGED CARE DEPT
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 82ND PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29572-4607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-1010
Provider Business Practice Location Address Fax Number:
843-497-6171
Provider Enumeration Date:
11/04/2005

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: 208800000X , with the licence number:  MD10499 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 771701 . This is a "WELLCARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 890508M , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP1418 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP454522 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104997 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340011957 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 80023039 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00360560 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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