MEDICARE: KEITH J KALISH DPM PA

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	213ES0131X	Foot Surgery Podiatrist	PO-001790	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PO-001790	OTHER	FL	STATE LIC#

General Provider Information

NPI Number	:	1295804367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH J KALISH DPM PA

Provider Business Mailing Address
First Line	:	2500 QUINCY AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4766
Country	:	US
Telephone Number	:	772-465-3207
Fax Number	:	772-465-3235

Provider Business Practice Location Address
First Line	:	1285 36TH ST
Second Line	:	SUITE 203
City	:	VERO BEACH
State	:	FL
Zip	:	32960-4885
Country	:	US
Telephone Number	:	772-567-0111
Fax Number	:	772-567-7117

Authorized Official
Title or Position	:	OWNER-PRESIDENT
Name	:	DR. KEITH JAY KALISH
Credential	:	D P M
Telephone Number	:	772-465-3207

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	05/07/2008

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1801958087 — KEITH J. KALISH DPM,PA
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Practice Fax: 772-567-7117

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