1710955752 NPI number — KIM MICHAEL REICHERT DPM

Table of content: KIM MICHAEL REICHERT DPM (NPI 1710955752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710955752 NPI number — KIM MICHAEL REICHERT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REICHERT
Provider First Name:
KIM
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1710955752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 FRANK SCOTT PKWY W
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62223-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-277-5700
Provider Business Mailing Address Fax Number:
618-257-7049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 FRANK SCOTT PKWY W
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62223-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-277-5700
Provider Business Practice Location Address Fax Number:
618-257-7049
Provider Enumeration Date:
03/08/2006

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: 213ES0103X , with the licence number:  016-003257 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , with the licence number: 016003257 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: STL2750010 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102179 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4134729 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 601-15944 . This is a "BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 480026528 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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