Provider Demographics
NPI:1710966114
Name:PRATZ, KEITH W (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:PRATZ
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 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:2 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-615-0063
Mailing Address - Fax:215-349-8144
Practice Address - Street 1:3400 CIVIC CENTER BLVD
Practice Address - Street 2:2 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-615-0063
Practice Address - Fax:215-349-8144
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064483207RH0003X
PAMD467231207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130187000Medicaid
MD417498400Medicaid
MN130187000Medicaid
H92315Medicare UPIN