1467402933 NPI number — BEATRICE KELLER CLINIC, PC

Table of content: (NPI 1467402933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467402933 NPI number — BEATRICE KELLER CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEATRICE KELLER CLINIC, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1467402933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13943 N 91ST AVE
Provider Second Line Business Mailing Address:
C-101
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-3687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-972-3992
Provider Business Mailing Address Fax Number:
623-974-9351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13943 N 91ST AVE
Provider Second Line Business Practice Location Address:
C-101
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-3687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-972-3992
Provider Business Practice Location Address Fax Number:
623-974-9351
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROFF
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-584-2127

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000838542 . This is a "EVERCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 188961600 . This is a "DEPT OF LABOR WORK COMP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0813027 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0846027 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: CT0844 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 838542 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1467402933 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 4265098 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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