Provider Demographics
NPI:1336568617
Name:WIRTH, KEITH MATTHEW
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MATTHEW
Last Name:WIRTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 HAZELWOOD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1243
Mailing Address - Country:US
Mailing Address - Phone:612-232-7800
Mailing Address - Fax:651-326-8770
Practice Address - Street 1:2945 HAZELWOOD ST STE 200
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1243
Practice Address - Country:US
Practice Address - Phone:612-232-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61495208600000X, 208600000X
390200000X
FLME150539208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program