1790819613 NPI number — KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION

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 1790819613 NPI number — KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1790819613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3510 UNOCAL PL STE 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-0918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-569-7860
Provider Business Mailing Address Fax Number:
707-545-5408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 BON AIR RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LARKSPUR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94939-1144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-927-0666
Provider Business Practice Location Address Fax Number:
415-927-6168
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KORVER
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-569-7860

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0090980 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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