Basic Information
Provider Information | |||||||||
NPI: | 1609977768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REGENSTEIN | ||||||||
FirstName: | FREDRIC | ||||||||
MiddleName: | GARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1430 TULANE AVE | ||||||||
Address2: | # 8535 | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701122632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8169327940 | ||||||||
FaxNumber: | 8169327957 | ||||||||
Practice Location | |||||||||
Address1: | 4320 WORNALL RD | ||||||||
Address2: | SUITE 240 | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641115941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8169327900 | ||||||||
FaxNumber: | 8169327920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 01/25/2016 | ||||||||
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 | 207RI0008X | 07834R | LA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207RT0003X | R9479 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Transplant Hepatology |
ID Information
ID | Type | State | Issuer | Description | 009942107 | 05 | AL |   | MEDICAID | 009913256 | 05 | AL |   | MEDICAID | 1609977768 | 05 | MO |   | MEDICAID | 05978098 | 05 | MS |   | MEDICAID | 1380890 | 05 | LA |   | MEDICAID |