Provider Demographics
NPI:1982794491
Name:DYER, KEITH A (PT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:DYER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47220-0010
Mailing Address - Country:US
Mailing Address - Phone:812-358-1714
Mailing Address - Fax:
Practice Address - Street 1:40 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1814
Practice Address - Country:US
Practice Address - Phone:812-752-6202
Practice Address - Fax:812-752-9533
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005009A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000363472OtherANTHEM PROVIDER NUMBER
IN200476840Medicaid
IN200476840Medicaid