1629169396 NPI number — MR. KEITH WILLIAM MCGILL PHYSICIAN ASSISTANT

Table of content: DR. BIDEMI YEMI OLANIYI-LEYIMU MD (NPI 1730165556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629169396 NPI number — MR. KEITH WILLIAM MCGILL PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGILL
Provider First Name:
KEITH
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

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:
1629169396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 S PICO AVE
Provider Second Line Business Mailing Address:
14342 BORA DRIVE LA MIRADA, CA 90638
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90802-6247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-432-2821
Provider Business Mailing Address Fax Number:
562-437-1353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S PICO AVE
Provider Second Line Business Practice Location Address:
14342 BORA DR LA MIRADA 90638
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-432-2821
Provider Business Practice Location Address Fax Number:
562-437-1353
Provider Enumeration Date:
09/27/2006

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: 207N00000X , with the licence number:  PA11313 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA 11313 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PA11313 . This is a "PHYSICIAN ASST. LICENSE #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".