Basic Information
Provider Information | |||||||||
NPI: | 1114953718 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KINNE | ||||||||
FirstName: | BEVERLY | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2000 | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | NY | ||||||||
PostalCode: | 125342000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188288363 | ||||||||
FaxNumber: | 5186973388 | ||||||||
Practice Location | |||||||||
Address1: | 358 MOUNTAIN VIEW RD | ||||||||
Address2: |   | ||||||||
City: | COPAKE | ||||||||
State: | NY | ||||||||
PostalCode: | 125161239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5183923900 | ||||||||
FaxNumber: | 5183921040 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2006 | ||||||||
LastUpdateDate: | 10/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F302098 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LX0001X | 360033 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
ID | Type | State | Issuer | Description | W79533 | 01 | NY | MEDICARE GROUP ; COLUMBIA MEMORIAL HOSPITAL | OTHER | 01909517 | 05 | NY |   | MEDICAID |