1689656605 NPI number — PITAYADET JUMRUSSIRIKUL M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689656605 NPI number — PITAYADET JUMRUSSIRIKUL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUMRUSSIRIKUL
Provider First Name:
PITAYADET
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1689656605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50306-9170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-633-3600
Provider Business Mailing Address Fax Number:
515-633-3838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5880 UNIVERSITY AVE STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50266-8209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-633-3653
Provider Business Practice Location Address Fax Number:
515-280-4630
Provider Enumeration Date:
11/16/2005

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: 207RC0000X , with the licence number:  36245 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 36245 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00261211 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0463471 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD4547 . This is a "RR GROUP NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P00261211 . This is a "RR MEDICARE NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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