Provider Demographics
NPI:1316137862
Name:KEESE, GREGORY R (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:KEESE
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 1:1107 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2604
Mailing Address - Country:US
Mailing Address - Phone:208-667-7459
Mailing Address - Fax:208-667-2631
Practice Address - Street 1:1107 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:208-667-7459
Practice Address - Fax:208-667-2631
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTL-3904174400000X
IDM11774174400000X
IDM-11774207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP01315338OtherPALMETTO GBA
ID1740539725OtherNEW ORGANIZATION NPI LINKED TO THIS INDIVIDUAL NPI
ID1083729438OtherOSSM ORGANIZATION LINKED TO THIS NPI
ID4639120001Medicare NSC
ID20001923Medicare PIN
20009488Medicare PIN
ID1740539725OtherNEW ORGANIZATION NPI LINKED TO THIS INDIVIDUAL NPI