1750397568 NPI number — EILEEN M KEOGH PT

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 1750397568 NPI number — EILEEN M KEOGH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEOGH
Provider First Name:
EILEEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1750397568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 BLYTHE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203-5814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-355-4370
Provider Business Mailing Address Fax Number:
704-355-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10620 PARK RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-667-2500
Provider Business Practice Location Address Fax Number:
704-667-2507
Provider Enumeration Date:
08/01/2006

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: 225100000X , with the licence number:  5068 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 295485 . This is a "MAMSI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1090E . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7210558 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 79106 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 112050 . This is a "WELLNESS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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