1922000280 NPI number — MADELYN M KECK A.R.N.P.

Table of content: MADELYN M KECK A.R.N.P. (NPI 1922000280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922000280 NPI number — MADELYN M KECK A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KECK
Provider First Name:
MADELYN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P.
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:
1922000280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844737
Provider Second Line Business Mailing Address:
ATTN: IPM CREDENTIALING
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-4737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-416-1726
Provider Business Mailing Address Fax Number:
903-416-1701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 N INDEPENDENCE STREET
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-249-3066
Provider Business Practice Location Address Fax Number:
580-234-5385
Provider Enumeration Date:
06/01/2005

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: 363L00000X , with the licence number:  R0039619 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500017031 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 444342284001 . This is a "BLUE CROSS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100088110A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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