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General NPI Number Information
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NPI Number | 1336568617
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Entity Type | Individual
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Provider Name | KEITH MATTHEW WIRTH
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Gender | Male
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 2945 HAZELWOOD ST STE 200
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City | MAPLEWOOD
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State | MN
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Zip | 55109-1243
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Country | US
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Telephone | 612-232-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 2945 HAZELWOOD ST STE 200
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City | MAPLEWOOD
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State | MN
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Zip | 55109-1243
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Country | US
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Telephone | 612-232-7800
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Fax | 651-326-8770
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 61495
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License Number State | MN
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