1316944812 NPI number — MS. DEBRA ROY KELLER PA

Table of content: MS. DEBRA ROY KELLER PA (NPI 1316944812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316944812 NPI number — MS. DEBRA ROY KELLER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
DEBRA
Provider Middle Name:
ROY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROY
Provider Other First Name:
DEBRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316944812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2655 RIDGEWAY AVE
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14626-4296
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-368-4000
Provider Business Mailing Address Fax Number:
585-225-2685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2655 RIDGEWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14626-4296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-368-4000
Provider Business Practice Location Address Fax Number:
585-225-2685
Provider Enumeration Date:
06/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  007617 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)