1497751663 NPI number — DR. KIM E PERSHALL MD

Table of content: DR. KIM E PERSHALL MD (NPI 1497751663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497751663 NPI number — DR. KIM E PERSHALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERSHALL
Provider First Name:
KIM
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:
1497751663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3811 24TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79410-1813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-796-0202
Provider Business Mailing Address Fax Number:
806-796-0496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3811 24TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-796-0202
Provider Business Practice Location Address Fax Number:
806-796-0496
Provider Enumeration Date:
06/22/2005

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: 174400000X , with the licence number:  J3574 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 86103 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: J3574 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YS0123X , with the licence number: J3574 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0602X , with the licence number: J3574 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 121351100 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 034333701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8P8420 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 37234 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F21125 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 148127701 . This is a "MEDICAID GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 040007969 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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