Provider Demographics
NPI:1093932972
Name:MONCHIK, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MONCHIK
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 1:285 PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-5794
Mailing Address - Country:US
Mailing Address - Phone:401-459-4001
Mailing Address - Fax:401-459-4006
Practice Address - Street 1:285 PROMENADE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-5794
Practice Address - Country:US
Practice Address - Phone:401-459-4001
Practice Address - Fax:401-459-4006
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12614207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0014606Medicare PIN
RI001460601Medicare PIN