Provider Demographics
NPI:1023342169
Name:ROBERT D IRVINE, MD, INC
Entity type:Organization
Organization Name:ROBERT D IRVINE, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAILEY
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-935-5465
Mailing Address - Street 1:670 PONAHAWAI ST
Mailing Address - Street 2:STE 115
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2660
Mailing Address - Country:US
Mailing Address - Phone:808-935-5465
Mailing Address - Fax:808-935-5467
Practice Address - Street 1:670 PONAHAWAI ST
Practice Address - Street 2:STE 115
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2660
Practice Address - Country:US
Practice Address - Phone:808-935-5465
Practice Address - Fax:808-935-5467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2284261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000036673OtherHAWAII MEDICAL SERVICES ASSOCIATION
HI03316401Medicaid
HI0000036673OtherHAWAII MEDICAL SERVICES ASSOCIATION
HID36148Medicare UPIN