Basic Information
| Provider Information | |||||||||
| NPI: | 1326018037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEISCH | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9165 PARK DR | ||||||||
| Address2: | |||||||||
| City: | MIAMI SHORES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331383163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055456685 | ||||||||
| FaxNumber: | 3055456687 | ||||||||
| Practice Location | |||||||||
| Address1: | 9165 PARK DR | ||||||||
| Address2: | |||||||||
| City: | MIAMI SHORES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331383163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055456685 | ||||||||
| FaxNumber: | 3055456687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME 62256 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 024162600 | 05 | FL | MEDICAID |