Provider Demographics
NPI:1336151273
Name:CHURCHWELL, KEITH B (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
Last Name:CHURCHWELL
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 1:20 YORK ST
Mailing Address - Street 2:TOMPKINS 106
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-2610
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:TOMPKINS 106
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:615-688-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT054404207RC0000X
TN25554207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3083503Medicaid
TN3083503Medicaid
TN3083505Medicare ID - Type Unspecified