Provider Demographics
NPI:1467402933
Name:BEATRICE KELLER CLINIC, PC
Entity Type:Organization
Organization Name:BEATRICE KELLER CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-584-2127
Mailing Address - Street 1:13943 N 91ST AVE
Mailing Address - Street 2:C-101
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3687
Mailing Address - Country:US
Mailing Address - Phone:623-972-3992
Mailing Address - Fax:623-974-9351
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:C-101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3687
Practice Address - Country:US
Practice Address - Phone:623-972-3992
Practice Address - Fax:623-974-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000838542OtherEVERCARE
AZ188961600OtherDEPT OF LABOR WORK COMP
AZ0813027OtherAETNA
AZ0846027OtherAETNA
AZCT0844OtherRAILROAD MEDICARE
AZ838542OtherUNITED HEALTH CARE
AZ1467402933OtherAHCCCS
AZ4265098OtherCIGNA
AZCT0844OtherRAILROAD MEDICARE
AZZWCKLLMedicare PIN