1407273899 NPI number — NICHOLAS RUST DPT

Table of content: KRISTI G KIDD M.D. (NPI 1447232228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407273899 NPI number — NICHOLAS RUST DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUST
Provider First Name:
NICHOLAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1407273899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310754
Provider Second Line Business Mailing Address:
DEPT 4101
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-0754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-255-3131
Provider Business Mailing Address Fax Number:
561-244-2591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 N CONGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33407-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-255-3131
Provider Business Practice Location Address Fax Number:
561-246-3715
Provider Enumeration Date:
03/24/2014

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: 225100000X , with the licence number:  PT28885 , 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: PT28885 . This is a "FLORIDA LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 010828900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109436800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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