Healthcare Provider Details

I. General information

NPI: 1861557795
Provider Name (Legal Business Name): KEITH P. RADBILL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 05/21/2023
Certification Date: 05/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W. MAPLE AVE.
MERCHANTVILLE NJ
08109
US

IV. Provider business mailing address

925 ROUTE 73 N STE H
MARLTON NJ
08053-1277
US

V. Phone/Fax

Practice location:
  • Phone: 856-375-1500
  • Fax: 609-482-8024
Mailing address:
  • Phone: 732-659-1159
  • Fax: 609-482-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MB07528500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB07528500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MB07528500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: