=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275588949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONY D KEYS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 N 2ND ST STE 315
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-6109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-336-4825
-----------------------------------------------------
Fax | 208-336-2292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2262
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-0812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-426-4770
-----------------------------------------------------
Fax | 909-426-4782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | M3871
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------