Provider Demographics
NPI:1770667925
Name:MEYER, KEITH A (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:MEYER
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:550 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2362
Practice Address - Country:US
Practice Address - Phone:417-678-5176
Practice Address - Fax:417-678-0675
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208558601Medicaid
MO208558601Medicaid
MO322013268Medicare PIN
MO059013230Medicare PIN