1821096629 NPI number — DR. KEITH W CHRISTMON MD

Table of content: DR. KEITH W CHRISTMON MD (NPI 1821096629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821096629 NPI number — DR. KEITH W CHRISTMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTMON
Provider First Name:
KEITH
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1821096629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
585 SOUTH BLVD E STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-3163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-206-1200
Provider Business Mailing Address Fax Number:
248-206-1206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1627 W BIG BEAVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-220-1560
Provider Business Practice Location Address Fax Number:
248-220-1563
Provider Enumeration Date:
07/14/2005

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: 207Q00000X , with the licence number:  KC067976 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0806334351 . This is a "BCBS BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080189691 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0806366101 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4469855 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0806366101 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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