Provider Demographics
NPI:1326102021
Name:P F BLOMGREN & D C KELLER PTR
Entity Type:Organization
Organization Name:P F BLOMGREN & D C KELLER PTR
Other - Org Name:GREENSBORO FAMILY PRACTICE ASSOCIATES LLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:F
Authorized Official - Last Name:BLOMGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-553-0045
Mailing Address - Street 1:317 W WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-8401
Mailing Address - Country:US
Mailing Address - Phone:336-553-0045
Mailing Address - Fax:336-553-0505
Practice Address - Street 1:317 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-8401
Practice Address - Country:US
Practice Address - Phone:336-553-0045
Practice Address - Fax:336-553-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001392336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1311190001OtherPALMETTO
NC01667OtherBCBS
NC89016679Medicaid
NC89016679Medicaid