Provider Demographics
NPI:1881100063
Name:GEORGE, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GEORGE
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 1:3640 COLONEL GLENN HWY.
Mailing Address - Street 2:117 HEALTH SCIENCES BLDG.
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435
Mailing Address - Country:US
Mailing Address - Phone:937-775-3458
Mailing Address - Fax:937-775-3434
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:053 STUDENT UNION
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435
Practice Address - Country:US
Practice Address - Phone:937-775-3407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-25
Last Update Date:2017-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program