1437119062 NPI number — KIM STUART VAN DER VEER DC, CCSP

Table of content: KIM STUART VAN DER VEER DC, CCSP (NPI 1437119062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437119062 NPI number — KIM STUART VAN DER VEER DC, CCSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DER VEER
Provider First Name:
KIM
Provider Middle Name:
STUART
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC, CCSP
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:
1437119062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1134 TROY SCHENECTADY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-783-1908
Provider Business Mailing Address Fax Number:
518-783-1909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1134 TROY SCHENECTADY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-783-1908
Provider Business Practice Location Address Fax Number:
518-783-1909
Provider Enumeration Date:
03/27/2006

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: 111NS0005X , with the licence number:  X005017 , 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: 141690724-01 . This is a "PRISM PROV. #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10019433 . This is a "CDPHP PROV. #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000445021001 . This is a "BLUE SHIELD PROV. #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 566114 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0013200 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 911601 . This is a "ACN GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: X3317 . This is a "BCBS PROV. #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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