1467402933 NPI number — BEATRICE KELLER CLINIC, PC

Table of Contents

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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