MEDICARE: P F BLOMGREN & D C KELLER PTR

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
1	207Q00000X	Family Medicine Physician	200001392336	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1311190001	OTHER	NC	PALMETTO
2	01667	OTHER	NC	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326102021
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P F BLOMGREN & D C KELLER PTR

Provider Business Mailing Address
First Line	:	317 W WENDOVER AVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-8401
Country	:	US
Telephone Number	:	336-553-0045
Fax Number	:	336-553-0505

Provider Business Practice Location Address
First Line	:	317 W WENDOVER AVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-8401
Country	:	US
Telephone Number	:	336-553-0045
Fax Number	:	336-553-0505

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. PETER F BLOMGREN
Credential	:	M.D.
Telephone Number	:	336-553-0045

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	10/06/2010

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Directions to “P F BLOMGREN & D C KELLER PTR ” Practice Location

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