1467475079 NPI number — TERESA D SMITH-KEIL FNP-C

Table of content: TERESA D SMITH-KEIL FNP-C (NPI 1467475079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467475079 NPI number — TERESA D SMITH-KEIL FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH-KEIL
Provider First Name:
TERESA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1467475079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 4TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHOTEAU
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59422-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-466-5763
Provider Business Mailing Address Fax Number:
406-466-5842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 4TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHOTEAU
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59422-9123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-466-5763
Provider Business Practice Location Address Fax Number:
406-466-5842
Provider Enumeration Date:
07/25/2006

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: 363LF0000X , with the licence number:  22046.0304 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 14907 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121007600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 456807 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 313564 . This is a "INDIVIDUAL BLUE CROSS NUM" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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