MEDICARE: KEITH D LARSON MD

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	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	22693	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639138431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH D LARSON MD

Provider Business Mailing Address
First Line	:	1511 NORTHWAY DR
Second Line	:	SUITE 202
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1261
Country	:	US
Telephone Number	:	320-217-8880
Fax Number	:	320-253-1822

Provider Business Practice Location Address
First Line	:	1511 NORTHWAY DR
Second Line	:	SUITE 202
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1261
Country	:	US
Telephone Number	:	320-217-8880
Fax Number	:	320-253-1822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	09/01/2009

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