Provider Demographics
NPI:1255330312
Name:SWANSON, KEITH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ROBERT
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:212 ELKS POINT RD
Practice Address - Street 2:STE 200
Practice Address - City:ZEPHYR COVE
Practice Address - State:NV
Practice Address - Zip Code:89448-8001
Practice Address - Country:US
Practice Address - Phone:775-589-8950
Practice Address - Fax:775-588-1299
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4005207XX0005X
CAC34400207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV30981Medicare PIN
NV2003106Medicaid
CAAP155YMedicare PIN
A35610Medicare UPIN
CAAP155ZMedicare PIN