Provider Demographics
NPI:1023185352
Name:KRUEGER, KEITH KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:KENNETH
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 47TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-9515
Mailing Address - Country:US
Mailing Address - Phone:320-240-8161
Mailing Address - Fax:651-631-0096
Practice Address - Street 1:2336 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4343
Practice Address - Country:US
Practice Address - Phone:651-631-0065
Practice Address - Fax:651-631-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine