Basic Information
| Provider Information | |||||||||
| NPI: | 1215150735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST FAMILY HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEKALB HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 S POLK ST | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644694030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164492123 | ||||||||
| FaxNumber: | 8164492125 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 S POLK ST | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644694030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164492123 | ||||||||
| FaxNumber: | 8164492125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIEHL | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8164492123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DB1347 | 01 | RAILROAD MEDICARE PTAN | OTHER | P900000 | 01 | MEDICARE PTAN | OTHER | 593197007 | 05 | MO | MEDICAID |