Provider Demographics
NPI:1396748109
Name:KNOELL, KEITH ALLEN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:KNOELL
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 1:2611 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-1600
Mailing Address - Country:US
Mailing Address - Phone:540-221-6702
Mailing Address - Fax:540-221-6704
Practice Address - Street 1:2611 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-1600
Practice Address - Country:US
Practice Address - Phone:540-221-6702
Practice Address - Fax:540-221-6704
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101058582207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396748109OtherANTHEM
VA1902258064Medicaid
VA3910782OtherCIGNA
VA5159805OtherAETNA
VA812009361OtherVIRGINIA HEALTH NETWORK
VAVVL693F992Medicare PIN
G94520Medicare UPIN
2180576OtherFIRST HEALTH ID#
VA541100071OtherTAX ID #
VA226854OtherBLUE CROSS BLUE SHIELD
VA070000289Medicare ID - Type UnspecifiedMEDICARE ID#