1801065040 NPI number — KITSAP PODIATRY PLLC

Table of content: (NPI 1801065040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801065040 NPI number — KITSAP PODIATRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KITSAP PODIATRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1801065040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10049 KITSAP MALL BLVD NW
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-8903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-698-2505
Provider Business Mailing Address Fax Number:
360-698-2514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10049 KITSAP MALL BLVD NW
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-698-2505
Provider Business Practice Location Address Fax Number:
360-698-2514
Provider Enumeration Date:
02/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AUFDERHEIDE
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-698-2505

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7125180 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134326283 . This is a "NPI - RYAN DOWNEY, DPM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DN6457 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8870860 . This is a "PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1730260241 . This is a "INDIVIDUAL NPI - PAUL W AUFDERHEIDE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1801065040 . This is a "GROUP NPI - KITSAP PODIATRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00630592 . This is a "RAILROAD MEDICARE GROUP MEMBER PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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