1275574600 NPI number — KEITH C LEVERENZ M.D.

Table of content: KEITH C LEVERENZ M.D. (NPI 1275574600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275574600 NPI number — KEITH C LEVERENZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEVERENZ
Provider First Name:
KEITH
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1275574600
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:
111 COLCHESTER AVE
Provider Second Line Business Mailing Address:
FAHC-WP2
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-1473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-847-2415
Provider Business Mailing Address Fax Number:
802-847-5324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
FAHC-WP2
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-1473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-2415
Provider Business Practice Location Address Fax Number:
802-847-5324
Provider Enumeration Date:
06/09/2006

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: 207L00000X , with the licence number:  042-0007211 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005247 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01165791 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".