1376157347 NPI number — RADIE KELLER

Table of content: RADIE KELLER (NPI 1376157347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376157347 NPI number — RADIE KELLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
RADIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1376157347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN CITY
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66006-0215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 GROVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALDWIN CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66006-9204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-594-2902
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2020

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: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 17-04219 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K03-07-8772 . This is a "DRIVER LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".