1982743159 NPI number — ROMAN HYSTAD KELLER D.O.

Table of content: ROMAN HYSTAD KELLER D.O. (NPI 1982743159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982743159 NPI number — ROMAN HYSTAD KELLER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
ROMAN
Provider Middle Name:
HYSTAD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1982743159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56302-7366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-257-7787
Provider Business Mailing Address Fax Number:
320-257-5596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1990 CONNECTICUT AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-2554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-257-5595
Provider Business Practice Location Address Fax Number:
320-257-5596
Provider Enumeration Date:
02/05/2007

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: 2085R0202X , with the licence number:  4420 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 52680 , 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: 1982743159 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com