MEDICARE: DR. ROBERT G KETTRICK 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	207L00000X	Anesthesiology Physician	ME72828	FL
2	207L00000X	Anesthesiology Physician	C10002939	DE

General Provider Information

NPI Number	:	1891821617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT G KETTRICK MD

Provider Business Mailing Address
First Line	:	CORPORATE CREDENTIALING
Second Line	:	P.O. BOX 269
City	:	WILMINGTON
State	:	DE
Zip	:	19899
Country	:	US
Telephone Number	:	302-651-5938
Fax Number	:	302-651-6077

Provider Business Practice Location Address
First Line	:	4600 TOUCHTON RD E
Second Line	:	SUITE 2500
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-8299
Country	:	US
Telephone Number	:	904-232-4262
Fax Number	:	904-232-4230

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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