Provider Demographics
NPI:1831154079
Name:GOULET, KEITH E (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:GOULET
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 1:2000 MEDICAL PKWY
Mailing Address - Street 2:SUITE 607
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3742
Mailing Address - Country:US
Mailing Address - Phone:410-266-1644
Mailing Address - Fax:410-266-1642
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:SUITE 607
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:410-266-1644
Practice Address - Fax:410-266-1642
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 012903207R00000X
MDH0070482207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGO1774721OtherHIGHMARK
PAGO1774721OtherPA BLUE CROSS/BLUE SHIELD
MDP00917232OtherMEDICARE RAILROAD
MDP00917232OtherMEDICARE RAILROAD
I46192Medicare UPIN