Healthcare Provider Details

I. General information

NPI: 1508934845
Provider Name (Legal Business Name): KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MEDOCINO AVENUE SUITE 200
SANTA ROSA CA
95403
US

IV. Provider business mailing address

3510 UNOCAL PL STE 207
SANTA ROSA CA
95403-0918
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-6166
  • Fax:
Mailing address:
  • Phone: 707-569-7860
  • Fax: 707-545-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG0522350
License Number StateCA

VIII. Authorized Official

Name: KEITH KORVER
Title or Position: PRESIDENT
Credential:
Phone: 707-569-7860