Provider Demographics
NPI:1366520900
Name:PALMER, KEITH E
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:PALMER
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 1:445 WELLESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941
Mailing Address - Country:UM
Mailing Address - Phone:415-383-6463
Mailing Address - Fax:
Practice Address - Street 1:445 WELLESLEY AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:UM
Practice Address - Phone:415-383-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33049207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G330490Medicaid
00G330490Medicare ID - Type Unspecified
F15813Medicare UPIN