Provider Demographics
NPI:1720198112
Name:PERRINE, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PERRINE
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 1:5250 FAR HILLS AVE
Mailing Address - Street 2:110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2382
Mailing Address - Country:US
Mailing Address - Phone:937-432-9810
Mailing Address - Fax:937-432-9815
Practice Address - Street 1:5250 FAR HILLS AVE
Practice Address - Street 2:110
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2382
Practice Address - Country:US
Practice Address - Phone:937-432-9810
Practice Address - Fax:937-432-9815
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84583208200000X
OH35.051583208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263826600Medicaid
FL263826600Medicaid
FLE36626Medicare UPIN