=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558503367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRENE KARDASHIAN M.D. , P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2009
-----------------------------------------------------
Last Update Date | 06/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14100 FIVAY RD SUITE 100
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-7180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-819-2534
-----------------------------------------------------
Fax | 727-819-2687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14100 FIVAY RD SUITE 100
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-7180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-819-2534
-----------------------------------------------------
Fax | 727-819-2687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHARON LARSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-819-2534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME79368
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------