Provider Demographics
NPI:1700850831
Name:MICHL, KEITH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:W
Last Name:MICHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1431
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255-1431
Mailing Address - Country:US
Mailing Address - Phone:802-362-9031
Mailing Address - Fax:802-362-7562
Practice Address - Street 1:7252 MAIN ST
Practice Address - Street 2:BUILDING A
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-1431
Practice Address - Country:US
Practice Address - Phone:802-362-9031
Practice Address - Fax:802-362-7562
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-000-7111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006032Medicaid
VTB85677Medicare UPIN