Provider Demographics
NPI:1154518231
Name:JACK E. KEISER,JR.,M.D.,PC
Entity type:Organization
Organization Name:JACK E. KEISER,JR.,M.D.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:KEISER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:315-253-2785
Mailing Address - Street 1:50 BROOKHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-9654
Mailing Address - Country:US
Mailing Address - Phone:315-252-0200
Mailing Address - Fax:
Practice Address - Street 1:50 BROOKHOLLOW DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-9654
Practice Address - Country:US
Practice Address - Phone:315-252-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137461208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00468575Medicaid
NY00468575Medicaid