Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 2000019730 | OH |
NPI | 1699279968 |
---|---|
Provider Name | Chad Marvin Keith |
First Address | Quincy, OH 43343 |
Second Address | Sidney, OH 45365-2401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2018 |
Last Update Date | 21/03/2018 |