1811066053 NPI number — DR. THOMAS KELLER PETTUS M.D.

Table of content: DR. THOMAS KELLER PETTUS M.D. (NPI 1811066053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811066053 NPI number — DR. THOMAS KELLER PETTUS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTUS
Provider First Name:
THOMAS
Provider Middle Name:
KELLER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1811066053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3366 OAKDALE AVE NO SUITE 315
Provider Second Line Business Mailing Address:
NORTH CLINIC
Provider Business Mailing Address City Name:
ROBBINSDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-587-7900
Provider Business Mailing Address Fax Number:
763-587-7989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3366 OAKDALE AVE NO SUITE 315
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
ROBBINSDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-587-7900
Provider Business Practice Location Address Fax Number:
763-587-7989
Provider Enumeration Date:
11/06/2006

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: 207RG0300X , with the licence number:  26453 , 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: 737568900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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