1154395762 NPI number — MR. KEITH WILLIAM CALVIN ATC

Table of content: MR. KEITH WILLIAM CALVIN ATC (NPI 1154395762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154395762 NPI number — MR. KEITH WILLIAM CALVIN ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALVIN
Provider First Name:
KEITH
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
1154395762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3749 PURITAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44212-4175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-273-8326
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3581 CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44212-3617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-273-0415
Provider Business Practice Location Address Fax Number:
330-273-0397
Provider Enumeration Date:
02/13/2006

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: 174400000X , with the licence number:  AT-000259 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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