MEDICARE: KEITH LARSON NEUROLOGY PLLC

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	261Q00000X	Clinic/Center	22693	MN

General Provider Information

NPI Number	:	1982937827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH LARSON NEUROLOGY PLLC

Provider Business Mailing Address
First Line	:	1511 NORTHWAY DR
Second Line	:	SUITE 202
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1261
Country	:	US
Telephone Number	:	320-217-8880
Fax Number	:	320-253-1822

Provider Business Practice Location Address
First Line	:	1511 NORTHWAY DR
Second Line	:	SUITE 202
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1261
Country	:	US
Telephone Number	:	320-217-8880
Fax Number	:	320-253-1822

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH DARRYL LARSON
Credential	:	M.D.
Telephone Number	:	320-217-8880

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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