Basic Information
Provider Information | |||||||||
NPI: | 1528422474 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUMMERSTON | ||||||||
FirstName: | KYLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 833 CHESTNUT ST STE 520 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2676064478 | ||||||||
FaxNumber: | 2673393761 | ||||||||
Practice Location | |||||||||
Address1: | 658 WHITE PLAINS RD | ||||||||
Address2: |   | ||||||||
City: | TARRYTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 105915104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003219999 | ||||||||
FaxNumber: | 2674791321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2016 | ||||||||
LastUpdateDate: | 11/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OS020485 | PA | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208100000X | 311469 | NY | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.