Provider Demographics
NPI:1699852996
Name:SHERRY, KEITH HAYDEN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:HAYDEN
Last Name:SHERRY
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 1:328 N MICHIGAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1244
Mailing Address - Country:US
Mailing Address - Phone:574-647-1842
Mailing Address - Fax:574-647-1825
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7459
Practice Address - Fax:574-647-3658
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035255A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2977962Medicaid
INE03937Medicare UPIN
MI2977962Medicaid