Healthcare Provider Details

I. General information

NPI: 1720089956
Provider Name (Legal Business Name): BRUCE W KEPPEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLMAR AVENUE SW AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201-3591
US

IV. Provider business mailing address

101 WILLMAR AVENUE SW AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201-3591
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5079
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5079
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number32303
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2744
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: