Provider Demographics
NPI:1063402972
Name:MYRICK, KEITH WELLINGTON (DPM)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WELLINGTON
Last Name:MYRICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6400 DUTCHMANS PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3340
Mailing Address - Country:US
Mailing Address - Phone:502-721-8288
Mailing Address - Fax:502-721-8792
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 215
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-721-8288
Practice Address - Fax:502-721-8792
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000000382017OtherBLUE PREFERRED (ANTHEM)
IN201363620Medicaid
KY80000318Medicaid
KY50007597OtherPASSPORT
KY50007597OtherPASSPORT
KY0000000382017OtherBLUE PREFERRED (ANTHEM)
ININ2284001Medicare PIN