=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326056359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN R KAFRISSEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 562 WYOMING AVE
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-552-3925
-----------------------------------------------------
Fax | 570-552-3907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 562 WYOMING AVE
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-552-3925
-----------------------------------------------------
Fax | 570-552-3907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD010164E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------