Healthcare Provider Details

I. General information

NPI: 1457411563
Provider Name (Legal Business Name): KEITH J. KALISH DPM, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 QUINCY AVE
FORT PIERCE FL
34947-4766
US

IV. Provider business mailing address

2500 QUINCY AVE
FORT PIERCE FL
34947-4766
US

V. Phone/Fax

Practice location:
  • Phone: 772-465-3207
  • Fax: 772-465-3235
Mailing address:
  • Phone: 772-465-3207
  • Fax: 772-465-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH JAY KALISH
Title or Position: OWNER
Credential: DPM
Phone: 772-465-3207