MEDICARE: KEITH J. KALISH DPM, PA

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PO 001790	OTHER	FL	STATE LIC#

General Provider Information

NPI Number	:	1457411563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH J. KALISH DPM, PA

Provider Business Mailing Address
First Line	:	2500 QUINCY AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4766
Country	:	US
Telephone Number	:	772-465-3207
Fax Number	:	772-465-3235

Provider Business Practice Location Address
First Line	:	2500 QUINCY AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4766
Country	:	US
Telephone Number	:	772-465-3207
Fax Number	:	772-465-3235

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEITH JAY KALISH
Credential	:	DPM
Telephone Number	:	772-465-3207

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	08/22/2020

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