1356378848 NPI number — MR. KEITH ALLEN WIEDRICH ATC

Table of content: MR. KEITH ALLEN WIEDRICH ATC (NPI 1356378848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356378848 NPI number — MR. KEITH ALLEN WIEDRICH ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEDRICH
Provider First Name:
KEITH
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
1356378848
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:
1220 7TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORHEAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56560-1570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-287-8402
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 7TH ST. S.
Provider Second Line Business Practice Location Address:
MSU MOORHEAD - ATHLETICS
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-477-2626
Provider Business Practice Location Address Fax Number:
218-477-5943
Provider Enumeration Date:
06/28/2006

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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