1013972165 NPI number — MONIREH MAHBOUBI KELLER M.D.

Table of content: MONIREH MAHBOUBI KELLER M.D. (NPI 1013972165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013972165 NPI number — MONIREH MAHBOUBI KELLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
MONIREH
Provider Middle Name:
MAHBOUBI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAHBOUBI-KELLER
Provider Other First Name:
MONIREH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1013972165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
727 E BETHANY HOME RD
Provider Second Line Business Mailing Address:
SUITE A-101
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85014-2198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-279-2400
Provider Business Mailing Address Fax Number:
602-279-5890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 E BETHANY HOME RD
Provider Second Line Business Practice Location Address:
SUITE A-101
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85014-2198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-279-2400
Provider Business Practice Location Address Fax Number:
602-279-5890
Provider Enumeration Date:
04/20/2006

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: 208000000X , with the licence number:  33085 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 968084 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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