1215331186 NPI number — MR. KEITH EDWARD GERBER CSW

Table of content: MR. KEITH EDWARD GERBER CSW (NPI 1215331186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215331186 NPI number — MR. KEITH EDWARD GERBER CSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GERBER
Provider First Name:
KEITH
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CSW
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:
1215331186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W GRIGGS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88001-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-647-2800
Provider Business Mailing Address Fax Number:
575-647-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 EAST TENTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-437-7404
Provider Business Practice Location Address Fax Number:
575-439-2860
Provider Enumeration Date:
10/21/2014

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18677037 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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