=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649353624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STUART M KILSTEIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 08/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12200 WARWICK BLVD STE 290
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-2344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-534-5454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 EDGEWATER ST
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-226-1047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 25MA06661300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | ME0070480
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 15204L
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 0101271302
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------