Provider Demographics
NPI:1104928043
Name:FRIEDENBERG, KEITH ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:FRIEDENBERG
Suffix:
Gender:
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:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-6211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8877 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6211
Practice Address - Country:US
Practice Address - Phone:440-205-1225
Practice Address - Fax:440-205-1275
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067316207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0985180Medicaid
OHF33648Medicare UPIN
OH0985180Medicaid