Provider Demographics
NPI:1720089956
Name:KEPPEN, BRUCE W (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:KEPPEN
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 1:101 WILLMAR AVENUE SW
Mailing Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3591
Mailing Address - Country:US
Mailing Address - Phone:320-231-5079
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:101 WILLMAR AVENUE SW
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3591
Practice Address - Country:US
Practice Address - Phone:320-231-5079
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32303207L00000X
SD2744207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5700338Medicaid
IA30114OtherBLUE CROSS
IA1198333Medicaid
SD5700338Medicaid
IA1198333Medicaid
SDS103291Medicare PIN