Provider Demographics
NPI:1437139938
Name:MCKLENDIN, KEITH PAUL (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:PAUL
Last Name:MCKLENDIN
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 1829
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1829
Mailing Address - Country:US
Mailing Address - Phone:208-666-3200
Mailing Address - Fax:208-666-3397
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-666-3200
Practice Address - Fax:208-666-3217
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1985190-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1132937OtherCIGNA MEDICARE - RANI
ID807137500Medicaid
MT0154297OtherMONTANA MEDICAID - NIIC
WA8455297Medicaid
IDB5558OtherBC ID - RANI
IDP00323045OtherRR MEDICARE - RANI
MT0154297OtherMONTANA MEDICAID - NIIC
P00322933Medicare PIN