Provider Demographics
NPI:1861504110
Name:FISH, KEITH R (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:FISH
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 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:DHMC DEPT OF SLEEP MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-3630
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:DHMC DEPT OF SLEEP MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1382969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V5140OtherHEALTHNET
36549485OtherTRI-CARE
010038296CT03OtherANTHEM BCBS
G80110Medicare UPIN
010038296CT03OtherANTHEM BCBS