MEDICARE: KEITH W BRANTLEY 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	207RC0000X	Cardiovascular Disease Physician	35063514B	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609852672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH W BRANTLEY MD

Provider Business Mailing Address
First Line	:	751 FOREST AVE
Second Line	:	STE 300
City	:	ZANESVILLE
State	:	OH
Zip	:	43701-2868
Country	:	US
Telephone Number	:	740-454-0804
Fax Number	:	740-450-3447

Provider Business Practice Location Address
First Line	:	751 FOREST AVE
Second Line	:	STE 301
City	:	ZANESVILLE
State	:	OH
Zip	:	43701-2868
Country	:	US
Telephone Number	:	740-454-0804
Fax Number	:	740-450-3447

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/13/2010

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Directions to “ KEITH W BRANTLEY MD” Practice Location

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