1376511881 NPI number — KEVIN T CUSTIS M D P C

Table of content: (NPI 1376511881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376511881 NPI number — KEVIN T CUSTIS M D P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN T CUSTIS M D P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1376511881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 MEADOW LARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLE MEAD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08502-4929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-431-7707
Provider Business Mailing Address Fax Number:
908-431-9329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
887 E NEW YORK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11203-1309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-778-0069
Provider Business Practice Location Address Fax Number:
718-778-0035
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CUSTIS
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
TYRONE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
718-363-6675

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  211807 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7505055 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 40 V182 . This is a "EMPIRE BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6016214 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01976654 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40V183 . This is a "EMPIRE BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2215900 . This is a "OXFORDN HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 211807 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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