Basic Information
Provider Information | |||||||||
NPI: | 1316931272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIEL | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | NORMAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1407 UNION AVE STE 700 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381043641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9018668622 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 995 S YATES RD STE 2 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381190882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9017675620 | ||||||||
FaxNumber: | 9016819820 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2005 | ||||||||
LastUpdateDate: | 02/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | DPM152 | TN | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
ID | Type | State | Issuer | Description | 220570717 | 05 | AR |   | MEDICAID | 3350519 | 05 | TN |   | MEDICAID | 3351646 | 05 | TN |   | MEDICAID | 1316931272 | 05 | MO |   | MEDICAID | 00935578 | 05 | MS |   | MEDICAID |