1154388734 NPI number — AMY JANE KEENUM DO, PHARMD

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 1154388734 NPI number — AMY JANE KEENUM DO, PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEENUM
Provider First Name:
AMY
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO, PHARMD
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:
1154388734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD
Provider Second Line Business Mailing Address:
A235
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-355-1300
Provider Business Mailing Address Fax Number:
517-355-1710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 SERVICE RD
Provider Second Line Business Practice Location Address:
A235
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48824-7015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-355-1300
Provider Business Practice Location Address Fax Number:
517-355-1710
Provider Enumeration Date:
04/27/2006

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:  5101011498 , 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: 1154388734 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3306480 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-41688 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 100032496 . This is a "PHP TENNCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 9206416 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN01G4 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 080164595 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3159480 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5954498 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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