1407851207 NPI number — KEITH FISHBEIN MD

Table of content: KEITH FISHBEIN MD (NPI 1407851207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407851207 NPI number — KEITH FISHBEIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHBEIN
Provider First Name:
KEITH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1407851207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23831 MARBELLA BAY RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BONITA SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34135-1830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-494-8404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23831 MARBELLA BAY RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BONITA SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34135-1830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-494-8404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2005

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: 207RC0000X , with the licence number:  25MA04065700 , 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: 4096206 . This is a "AETNA PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0031965000 . This is a "AMERIHEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: F06621 . This is a "HEALTHNET ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: MES208 . This is a "OXFORD PROVIDER #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1130611 . This is a "HORIZON NJ HEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 222908710 . This is a "TAX IDENTIFICATION #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 34706 . This is a "AETNA HMO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0176206 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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