1891956918 NPI number — GEORGE J KELEN MD PLLC

Table of content: (NPI 1891956918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891956918 NPI number — GEORGE J KELEN MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE J KELEN MD PLLC
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:
LAKESHORE CARDIOLOGY
Provider Other Organization Name Type Code:
3
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:
1891956918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
913 E LUDINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-845-7677
Provider Business Mailing Address Fax Number:
231-843-0773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
913 E LUDINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49431-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-845-7677
Provider Business Practice Location Address Fax Number:
231-843-0773
Provider Enumeration Date:
06/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KELEN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-845-7677

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  4301079843 , 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: 4579580 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA9989 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com