Provider Demographics
NPI:1073713095
Name:KELLY REBER DPM, PC
Entity Type:Organization
Organization Name:KELLY REBER DPM, PC
Other - Org Name:NORTHERN ARIZONA PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-779-5111
Mailing Address - Street 1:940 N SWITZER CANYON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4852
Mailing Address - Country:US
Mailing Address - Phone:928-779-5111
Mailing Address - Fax:928-779-1374
Practice Address - Street 1:940 N SWITZER CANYON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4852
Practice Address - Country:US
Practice Address - Phone:928-779-5111
Practice Address - Fax:928-779-1374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0195213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77787Medicare UPIN
1028440001Medicare NSC