1801002712 NPI number — MAUREEN HERNANDEZ OTR

Table of content: MAUREEN HERNANDEZ OTR (NPI 1801002712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801002712 NPI number — MAUREEN HERNANDEZ OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDEZ
Provider First Name:
MAUREEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARNEY
Provider Other First Name:
MAUREEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801002712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAVENWORTH
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66048-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-651-1000
Provider Business Mailing Address Fax Number:
913-651-3030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 S 4TH TRAFFICWAY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-5012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-651-1000
Provider Business Practice Location Address Fax Number:
913-651-3030
Provider Enumeration Date:
05/15/2007

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: 225X00000X , with the licence number:  17-01940 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 013843 . This is a "BCBS OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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