1518049113 NPI number — MRS. ALYSSA VICTORIA KEEGAN OTRL

Table of content: MRS. ALYSSA VICTORIA KEEGAN OTRL (NPI 1518049113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518049113 NPI number — MRS. ALYSSA VICTORIA KEEGAN OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEEGAN
Provider First Name:
ALYSSA
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PORTO
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
VICTORIA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518049113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 KINGSLEY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GANSEVOORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-695-9408
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 SARATOGA BRIDGES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-587-5747
Provider Business Practice Location Address Fax Number:
518-583-9607
Provider Enumeration Date:
10/20/2006

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: 225X00000X , with the licence number:  011563 , 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)