Healthcare Provider Details

I. General information

NPI: 1770509580
Provider Name (Legal Business Name): DAVID RALPH KEIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 VOYAGER DR
GREEN BAY WI
54311-8303
US

IV. Provider business mailing address

PO BOX 19070 PREVEA HEALTH
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax: 920-431-1849
Mailing address:
  • Phone: 920-496-4700
  • Fax: 920-431-1849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number33638
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: