1558358796 NPI number — MRS. JYOTHI BHANU KESHA M.D.

Table of content: MRS. JYOTHI BHANU KESHA M.D. (NPI 1558358796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558358796 NPI number — MRS. JYOTHI BHANU KESHA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KESHA
Provider First Name:
JYOTHI
Provider Middle Name:
BHANU
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BHANU
Provider Other First Name:
JYOTHI
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558358796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
SUITE 240N
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-999-6909
Provider Business Mailing Address Fax Number:
651-297-6115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 OSBORNE RD NE
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432-2765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-783-8582
Provider Business Practice Location Address Fax Number:
763-783-8616
Provider Enumeration Date:
10/03/2005

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: 208800000X , with the licence number:  42668 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 307127800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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