1962476739 NPI number — KEVIN M RHODUS CRNA

Table of content: KEVIN M RHODUS CRNA (NPI 1962476739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962476739 NPI number — KEVIN M RHODUS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RHODUS
Provider First Name:
KEVIN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1962476739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 WAPITI LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-7124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-947-6660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1397 WEIMER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-6253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-758-8883
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2006

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: 367500000X , with the licence number:  C-APN.0000892-C-CRNA , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: R54743 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10020355 . This is a "LOVELACE HP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 59332841 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: T0426 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 956899 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202000353 . This is a "PRESBYTERIAN HP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM006B15 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 9829750 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00329269 . This is a "RR MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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