MEDICARE: DR. KEITH L. BLAUER M.D.

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	174400000X	Specialist	567553-1205 & 8905	UT

General Provider Information

NPI Number	:	1962475350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH L. BLAUER M.D.

Provider Business Mailing Address
First Line	:	10150 PETUNIA WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4380
Country	:	US
Telephone Number	:	801-878-8888
Fax Number	:	801-878-8890

Provider Business Practice Location Address
First Line	:	10150 PETUNIA WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4380
Country	:	US
Telephone Number	:	801-878-8888
Fax Number	:	801-878-8890

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	07/08/2007

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