Provider Demographics
NPI:1013166925
Name:KEHOE, CULLEN TIMOTHY (DO)
Entity Type:Individual
Prefix:DR
First Name:CULLEN
Middle Name:TIMOTHY
Last Name:KEHOE
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:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-4990
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-4990
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122047207P00000X
ND11215207P00000X
WI53435-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKEHOECULOtherMERCYCARE INSURANCE
WI1013166925Medicaid
WI1013166925OtherBCBSWI
IL$$$$$$$$$ 1Medicaid
WI1013166925Medicaid