Provider Demographics
NPI:1376580274
Name:KETSCHE, REINHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:REINHARD
Middle Name:
Last Name:KETSCHE
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-0669
Mailing Address - Country:US
Mailing Address - Phone:770-963-9905
Mailing Address - Fax:
Practice Address - Street 1:745 POPLAR RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1618
Practice Address - Country:US
Practice Address - Phone:770-400-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029194207L00000X
GA29194207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29919Medicare UPIN
GA05BDKSWMedicare ID - Type Unspecified