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NPI Code Detail

MEDICARE: MR. KEITH A BERENS PAC

MEDICARE: MR. KEITH A BERENS PAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AS0400XSurgical Physician AssistantPA2020-0079NM
2363AS0400XSurgical Physician AssistantPA9101561FL
3363A00000XPhysician Assistant2814NH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
259039584OTHERFLBSAL
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1174505788
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KEITH A BERENS PAC
Provider Business Mailing Address
First Line : PO BOX 95590
Second Line :
City : SOUTH JORDAN
State : UT
Zip : 84095-0590
Country : US
Telephone Number : 801-784-0954
Fax Number : 801-352-7976
Provider Business Practice Location Address
First Line : 125 BAPTIST WAY STE 4C
Second Line :
City : PENSACOLA
State : FL
Zip : 32503-2274
Country : US
Telephone Number : 448-227-6330
Fax Number : 850-626-9606
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/18/2005
Last Update Date : 06/15/2026

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Directions to “ MR. KEITH A BERENS PAC” Practice Location

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