Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 036122047 | IL |
Y | 207P00000X | Emergency Physician | 53435-21 | WI |
NPI | 1013166925 |
---|---|
Provider Name | Dr. Cullen Timothy Kehoe |
First Address | Lake Geneva, WI 53147-2655 |
Second Address | Lake Geneva, WI 53147-2655 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2008 |
Last Update Date | 23/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1013166925 | (05) | WI |
1013166925 | BCBSWI (01) | WI |
KEHOECUL | MERCYCARE INSURANCE (01) | WI |