1265424675 NPI number — DEANNA L PORTE KEENE MD

Table of content: DEANNA L PORTE KEENE MD (NPI 1265424675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265424675 NPI number — DEANNA L PORTE KEENE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTE KEENE
Provider First Name:
DEANNA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PORTE
Provider Other First Name:
DEANNA
Provider Other Middle Name:
LYNNE SPORKE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265424675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9660 WICKER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST JOHN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46373-9487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-924-2444
Provider Business Mailing Address Fax Number:
219-924-2488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 45TH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-3962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-924-2444
Provider Business Practice Location Address Fax Number:
219-924-2488
Provider Enumeration Date:
08/22/2005

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: 207R00000X , with the licence number:  01029185 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000360206 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351107009014 . This is a "TRICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P0029848 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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