1972724821 NPI number — BETH A KELLEY NP, CNM

Table of content: BETH A KELLEY NP, CNM (NPI 1972724821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972724821 NPI number — BETH A KELLEY NP, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
BETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP, CNM
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:
1972724821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 E CHICAGO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURGIS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49091-8524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-659-6747
Provider Business Mailing Address Fax Number:
269-659-6746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 E. CHICAGO ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STURGIS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49091-2372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-659-6747
Provider Business Practice Location Address Fax Number:
269-659-6746
Provider Enumeration Date:
05/01/2007

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:  4704194227 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704194227 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: 4704194227 , 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: 000000612032 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200932840 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160G510560 . This is a "BCBS GROUP-WOMENS SERVICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700G560080 . This is a "BCBS GROUP-THREE RIVERS HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".