Basic Information
Provider Information
NPI: 1003149345
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TEBBE
FirstName: KEITH
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: ATC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7300 E INDIANA ST
Address2: SUITE 102
City: EVANSVILLE
State: IN
PostalCode: 477152794
CountryCode: US
TelephoneNumber: 8124760409
FaxNumber: 8124761016
Practice Location
Address1: 2121 WILLOW ST
Address2:  
City: VINCENNES
State: IN
PostalCode: 475915355
CountryCode: US
TelephoneNumber: 8128821141
FaxNumber: 8122550045
Other Information
ProviderEnumerationDate: 09/17/2009
LastUpdateDate: 09/17/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2255A2300X36001625AINY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer

No ID Information.


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