Provider Demographics
NPI:1790819613
Name:KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KEITH F KORVER MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:F
Authorized Official - Last Name:KORVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-569-7860
Mailing Address - Street 1:3510 UNOCAL PL STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0918
Mailing Address - Country:US
Mailing Address - Phone:707-569-7860
Mailing Address - Fax:707-545-5408
Practice Address - Street 1:2 BON AIR RD
Practice Address - Street 2:STE 100
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1144
Practice Address - Country:US
Practice Address - Phone:415-927-0666
Practice Address - Fax:415-927-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090980Medicaid
CAZZZ04584ZMedicare PIN