Provider Demographics
NPI:1649470204
Name:ALLEN, KEITH A (MBCHBBAO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MBCHBBAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W STOUT ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-5000
Mailing Address - Country:US
Mailing Address - Phone:715-234-1515
Mailing Address - Fax:
Practice Address - Street 1:15746 FREMONT WAY
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6531
Practice Address - Country:US
Practice Address - Phone:715-205-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51841207P00000X
IL036159388207P00000X
WI54561-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN930003421Medicare PIN