1679555866 NPI number — DR. EDWIN F ETCUBANEZ MD

Table of content: DR. EDWIN F ETCUBANEZ MD (NPI 1679555866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679555866 NPI number — DR. EDWIN F ETCUBANEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETCUBANEZ
Provider First Name:
EDWIN
Provider Middle Name:
F
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:
1679555866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 KANOELEHUA AVE
Provider Second Line Business Mailing Address:
B9
Provider Business Mailing Address City Name:
HILO
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96720-6500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-981-1700
Provider Business Mailing Address Fax Number:
808-981-1701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 KANOELEHUA AVE
Provider Second Line Business Practice Location Address:
B9
Provider Business Practice Location Address City Name:
HILO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96720-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-981-1700
Provider Business Practice Location Address Fax Number:
808-981-1701
Provider Enumeration Date:
11/15/2005

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: 207Q00000X , with the licence number:  4301045023 , 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)

  • Identifier: 540Z90298 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0800900422 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1009100 . This is a "HEALTH ADVANTAGE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "COMMUNITY BLUE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080D410020 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1009110 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4395680 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080D410020 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: D72564 . This is a "HEALTH NET FEDERAL SERVIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4433932 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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