=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548312432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD JAMES KROEGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 HARDEE RD SUITE 103 B
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-0285
-----------------------------------------------------
Fax | 252-523-4474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 HARDEE RD SUITE 103 B
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-0285
-----------------------------------------------------
Fax | 252-523-4474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 27814
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------