Provider Demographics
NPI:1790798221
Name:GRAU, KEITH EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:GRAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:E
Other - Last Name:GRAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2252 WILDWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1221
Practice Address - Country:US
Practice Address - Phone:503-361-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26789207R00000X
PAMD019815E207R00000X
MT11144207R00000X
CAG87852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGR081965Medicare ID - Type Unspecified
PAC29278Medicare UPIN