1497852693 NPI number — MR. RICHARD THOMAS KASBOW PA-C

Table of content: MR. RICHARD THOMAS KASBOW PA-C (NPI 1497852693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497852693 NPI number — MR. RICHARD THOMAS KASBOW PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KASBOW
Provider First Name:
RICHARD
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KASBOR
Provider Other First Name:
RICHARD
Provider Other Middle Name:
THOMAS
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1497852693
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:
9651 S RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEBOYGAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49721-9412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-625-2148
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 S OTSEGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAYLORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49735-1725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-732-7525
Provider Business Practice Location Address Fax Number:
989-732-6577
Provider Enumeration Date:
09/20/2006

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: 363A00000X , with the licence number:  5601001620 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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