1649271990 NPI number — KIANOOSH KAVEH DO PA

Table of content: (NPI 1649271990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649271990 NPI number — KIANOOSH KAVEH DO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIANOOSH KAVEH DO PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1649271990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3221 TAMIAMI TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-8002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-505-8720
Provider Business Mailing Address Fax Number:
941-505-8747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3221 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-8002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-505-8720
Provider Business Practice Location Address Fax Number:
941-505-8747
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KAVEH
Authorized Official First Name:
KIANOOSH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-505-8720

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  OS8229 , 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: 2142967000 . This is a "AMERIHEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2148967000 . This is a "INDEPENDENCE BC PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2985402 . This is a "AETNA BLUE BELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 24133 . This is a "BCBS FL GRP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 471501 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 651256 . This is a "COMBINED INS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0323474 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 30030181 . This is a "KEYSTONE MERCY HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: N279248 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001457915 . This is a "BCBS HIGHMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9814293 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 265580200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000ZCY746 . This is a "BCBS MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7405063 . This is a "MAMSI INS" identifier . This identifiers is of the category "OTHER".
  • Identifier: KKA150339 . This is a "BCBS EXCELLUS NY" identifier . This identifiers is of the category "OTHER".




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