Provider Demographics
NPI:1205019643
Name:NORTHEAST FAMILY PRACTICE
Entity Type:Organization
Organization Name:NORTHEAST FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-898-0150
Mailing Address - Street 1:6200 CLEVELAND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-8608
Mailing Address - Country:US
Mailing Address - Phone:614-898-0150
Mailing Address - Fax:614-898-0694
Practice Address - Street 1:6200 CLEVELAND AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-8608
Practice Address - Country:US
Practice Address - Phone:614-898-0150
Practice Address - Fax:614-898-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH052152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherTAX ID
OH=========OtherTAX ID