1295774529 NPI number — DR. CAROL E KESHOCK D.P.M.

Table of content: DR. CAROL E KESHOCK D.P.M. (NPI 1295774529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295774529 NPI number — DR. CAROL E KESHOCK D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KESHOCK
Provider First Name:
CAROL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1295774529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAY VILLAGE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44140-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-871-4700
Provider Business Mailing Address Fax Number:
440-871-4702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26908 DETROIT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-2398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-892-6655
Provider Business Practice Location Address Fax Number:
440-871-9817
Provider Enumeration Date:
06/05/2006

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: 213E00000X , with the licence number:  36-002485 , 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)

  • Identifier: 0876208 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480027726 . This is a "MEDICARE RAILROAD PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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