Provider Demographics
NPI:1194474387
Name:KEISER MEDICAL GROUP
Entity type:Organization
Organization Name:KEISER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KEISER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:615-775-7720
Mailing Address - Street 1:2513 WHITE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-2731
Mailing Address - Country:US
Mailing Address - Phone:615-775-7720
Mailing Address - Fax:
Practice Address - Street 1:2513 WHITE AVE APT 7
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-2731
Practice Address - Country:US
Practice Address - Phone:615-775-7720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty