Provider Demographics
NPI:1730398165
Name:HARMON, KEITH KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:KEVIN
Last Name:HARMON
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 1:1811 NORTH DIXIE AVENUE, SUITE 104, #113
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:208-406-4058
Mailing Address - Fax:
Practice Address - Street 1:1700 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9497
Practice Address - Country:US
Practice Address - Phone:270-769-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10274208600000X
OH35.126319208600000X
KY48134208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136330Medicaid
ID808084800Medicaid
ID000010168443OtherREGENCE BLUE SHIELD
ID1059288OtherDESERET MUTUAL BENEFIT ADMINISTRATORS
ID26-2759132OtherRAIL ROAD MEDICARE
ID77535OtherBLUE CROSS
ID26-2759132OtherRAIL ROAD MEDICARE
OH0136330Medicaid
OHH350940Medicare PIN