Provider Demographics
NPI:1740206929
Name:NORTHPARKE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:NORTHPARKE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN COOWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-390-1700
Mailing Address - Street 1:211 NORTHPARKE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503
Mailing Address - Country:US
Mailing Address - Phone:937-390-1700
Mailing Address - Fax:937-390-2471
Practice Address - Street 1:211 NORTHPARKE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503
Practice Address - Country:US
Practice Address - Phone:937-390-1700
Practice Address - Fax:937-390-2471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0154658Medicaid
OH0154658Medicaid