Provider Demographics
NPI:1326190653
Name:KEBAETSE, MAIKUTLO B (PHD, PT)
Entity Type:Individual
Prefix:MR
First Name:MAIKUTLO
Middle Name:B
Last Name:KEBAETSE
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:PAULSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08066-0277
Mailing Address - Country:US
Mailing Address - Phone:185-622-0400
Mailing Address - Fax:856-224-0466
Practice Address - Street 1:541 MANTUA AVE
Practice Address - Street 2:
Practice Address - City:PAULSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08066-1178
Practice Address - Country:US
Practice Address - Phone:185-622-4000
Practice Address - Fax:856-224-0466
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00685900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2410669000OtherAMERIHEALTH GROUP ID
NJ2410631000OtherAMERIJEALTH IND. ID#
NJ2410631000OtherAMERIJEALTH IND. ID#
NJ090041Medicare PIN