1801850508 NPI number — DR. KENNETH TAYLOR ROOST MD

Table of content: DR. KENNETH TAYLOR ROOST MD (NPI 1801850508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801850508 NPI number — DR. KENNETH TAYLOR ROOST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROOST
Provider First Name:
KENNETH
Provider Middle Name:
TAYLOR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1801850508
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:
1828 EL CAMINO REAL
Provider Second Line Business Mailing Address:
STE 604
Provider Business Mailing Address City Name:
BURLINGAME
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94010-3120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-697-9146
Provider Business Mailing Address Fax Number:
650-697-5514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1828 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
STE 604
Provider Business Practice Location Address City Name:
BURLINGAME
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94010-3120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-697-9146
Provider Business Practice Location Address Fax Number:
650-697-5514
Provider Enumeration Date:
04/12/2006

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: 207RG0100X , with the licence number:  G27727 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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