1083070536 NPI number — DR. PHILLIP KECK PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083070536 NPI number — DR. PHILLIP KECK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KECK
Provider First Name:
PHILLIP
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1083070536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11350 MCCORMICK RD EXECUTIVE PLAZA 1
Provider Second Line Business Mailing Address:
STE 501
Provider Business Mailing Address City Name:
HUNT VALLEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-738-4331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 WILKES RIDGE PKWY
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23233-7460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-270-7262
Provider Business Practice Location Address Fax Number:
804-270-7264
Provider Enumeration Date:
01/13/2016

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: 103T00000X , with the licence number:  0810005353 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TH0004X , with the licence number: 0810005353 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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