1306988126 NPI number — MR. TIMOTHY RICHARD KRUSE M.D.

Table of content: MR. TIMOTHY RICHARD KRUSE M.D. (NPI 1306988126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306988126 NPI number — MR. TIMOTHY RICHARD KRUSE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUSE
Provider First Name:
TIMOTHY
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1306988126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 E VALLEY RD
Provider Second Line Business Mailing Address:
UNIT 202C
Provider Business Mailing Address City Name:
BASALT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81621-8370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-927-8563
Provider Business Mailing Address Fax Number:
970-300-2883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 E VALLEY RD
Provider Second Line Business Practice Location Address:
UNIT 202C
Provider Business Practice Location Address City Name:
BASALT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81621-8370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-927-8563
Provider Business Practice Location Address Fax Number:
970-300-2883
Provider Enumeration Date:
02/12/2007

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: 207Q00000X , with the licence number:  37271-CO , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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