Basic Information
| Provider Information | |||||||||
| NPI: | 1740539725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREGORY R. KEESE, M.D., P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 W IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086677459 | ||||||||
| FaxNumber: | 2086672631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 W IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086677459 | ||||||||
| FaxNumber: | 2086672631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | POOLE | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | BOOKKEEPER | ||||||||
| AuthorizedOfficialTelephone: | 2086677459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1316137862 | 01 | ID | PLEASE LINK TO INDIVIDUAL NPI # | OTHER | 1740539725 | 05 | ID | MEDICAID |