Provider Demographics
NPI:1528105194
Name:CROSS, KEITH PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:PHILLIP
Last Name:CROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-7551
Mailing Address - Fax:503-494-4997
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7551
Practice Address - Fax:503-494-4997
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294757-1208000000X, 2080P0204X, 207R00000X
ORMD214291208000000X, 207PP0204X, 207R00000X
KY409902080P0204X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200882960Medicaid
KY7100025500Medicaid
NY03822786Medicaid