1588755318 NPI number — KIMBERLY KROLL OTR

Table of content: KIMBERLY KROLL OTR (NPI 1588755318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588755318 NPI number — KIMBERLY KROLL OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KROLL
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1588755318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 N 19TH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55812-1133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55718-9228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-689-5385
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2006

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: 225X00000X , with the licence number:  101379 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6406076 . This is a "NAHC MD INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP45791 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 40902900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 530R8KR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 088H0O . This is a "NAHC BC INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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