Provider Demographics
NPI:1962477349
Name:HARRISON, KEITH W (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3241
Mailing Address - Country:US
Mailing Address - Phone:610-327-4200
Mailing Address - Fax:610-327-8160
Practice Address - Street 1:23 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1467
Practice Address - Country:US
Practice Address - Phone:610-367-2259
Practice Address - Fax:610-367-0505
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005855L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
518786Medicare ID - Type Unspecified
ALC34799Medicare UPIN
80053376Medicare PIN