MEDICARE: DR. KEITH ROBERT SWANSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	4005	NV
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	C34400	CA

General Provider Information

NPI Number	:	1255330312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH ROBERT SWANSON MD

Provider Business Mailing Address
First Line	:	1111 EMERALD BAY RD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-6207
Country	:	US
Telephone Number	:	530-543-5659
Fax Number	:	530-541-8723

Provider Business Practice Location Address
First Line	:	212 ELKS POINT RD
Second Line	:	STE 200
City	:	ZEPHYR COVE
State	:	NV
Zip	:	89448-8001
Country	:	US
Telephone Number	:	775-589-8950
Fax Number	:	775-588-1299

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/16/2014

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