Provider Demographics
NPI:1184675365
Name:KEHOE, RYAN J (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:KEHOE
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 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-395-4160
Mailing Address - Fax:262-395-4159
Practice Address - Street 1:19475 W NORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4199
Practice Address - Country:US
Practice Address - Phone:262-395-4160
Practice Address - Fax:262-395-4159
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44735207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG1663OtherMEDICARE RAILROAD
WI34932600Medicaid
WI001401410Medicare PIN
WII65027Medicare UPIN