Basic Information
| Provider Information | |||||||||
| NPI: | 1649298357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORB | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 CLAREMONT ST STE C | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067585155 | ||||||||
| FaxNumber: | 4067585166 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 CLAREMONT ST STE C | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067585155 | ||||||||
| FaxNumber: | 4067585166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 5257 | MT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 36648 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | 5257 | MT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01366483 | 05 | CO | MEDICAID | 112948 | 01 | CO | VALUE OPTIONS | OTHER | 810445794 | 01 | CO | TAX ID# | OTHER |