1326190653 NPI number — MR. MAIKUTLO B KEBAETSE PH.D, P.T.

Table of content: MR. MAIKUTLO B KEBAETSE PH.D, P.T. (NPI 1326190653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326190653 NPI number — MR. MAIKUTLO B KEBAETSE PH.D, P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEBAETSE
Provider First Name:
MAIKUTLO
Provider Middle Name:
B
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D, P.T.
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:
1326190653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 277
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAULSBORO
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08066-0277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
185-622-0400
Provider Business Mailing Address Fax Number:
856-224-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 MANTUA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAULSBORO
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08066-1178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
185-622-4000
Provider Business Practice Location Address Fax Number:
856-224-0466
Provider Enumeration Date:
01/17/2007

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: 225100000X , with the licence number:  40QA00685900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2410669000 . This is a "AMERIHEALTH GROUP ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2410631000 . This is a "AMERIJEALTH IND. ID#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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