1578688552 NPI number — AMY M. KELLER OD PC

Table of content: (NPI 1578688552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578688552 NPI number — AMY M. KELLER OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMY M. KELLER OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578688552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 W UPTON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REED CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49677-1129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-832-3133
Provider Business Mailing Address Fax Number:
231-832-1417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 W UPTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REED CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49677-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-832-3133
Provider Business Practice Location Address Fax Number:
231-832-1417
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-832-3133

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  AK003308 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2883730 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1336259761 . This is a "DR. KELLER'S PERSONAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0N43890 . This is a "MEDICARE ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0289080001 . This is a "ADMINISTAR FEDERAL, INC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1184727612 . This is a "DR. WILSON'S PERSONAL NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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