1972617223 NPI number — PETER WHITEHEAD KEARNS CRNA

Table of content: PETER WHITEHEAD KEARNS CRNA (NPI 1972617223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972617223 NPI number — PETER WHITEHEAD KEARNS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEARNS
Provider First Name:
PETER
Provider Middle Name:
WHITEHEAD
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:
1972617223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4135 BOARDMAN CANFIELD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CANFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44406-9803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-286-5330
Provider Business Mailing Address Fax Number:
330-286-5396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LIVERPOOL
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43920-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-386-2017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2006

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:  RN251756-1 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: RN354157L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2615680 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017673070004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218848TV6 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P01613589 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 12215037 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2236066 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8226988 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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