1750382347 NPI number — KIM K COUNTRYMAN D.O.

Table of content: KIM K COUNTRYMAN D.O. (NPI 1750382347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750382347 NPI number — KIM K COUNTRYMAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUNTRYMAN
Provider First Name:
KIM
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1750382347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/22/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7147 VISTA DR STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50266-9313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-875-9925
Provider Business Mailing Address Fax Number:
515-875-9923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 NE DARTMOOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-875-9890
Provider Business Practice Location Address Fax Number:
515-875-9892
Provider Enumeration Date:
08/03/2005

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:  DO-02312 , 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: 1043646 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59276 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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