Provider Demographics
NPI:1891821617
Name:KETTRICK, ROBERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:KETTRICK
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:CORPORATE CREDENTIALING
Mailing Address - Street 2:P.O. BOX 269
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19899
Mailing Address - Country:US
Mailing Address - Phone:302-651-5938
Mailing Address - Fax:302-651-6077
Practice Address - Street 1:4600 TOUCHTON RD E
Practice Address - Street 2:SUITE 2500
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8299
Practice Address - Country:US
Practice Address - Phone:904-232-4262
Practice Address - Fax:904-232-4230
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72828207L00000X
DEC10002939207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F04114Medicare UPIN
21045Medicare ID - Type Unspecified