Basic Information
| Provider Information | |||||||||
| NPI: | 1992117865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUMMINGS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 8TH AVE NE STE 320 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254553600 | ||||||||
| FaxNumber: | 4254553920 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 8TH AVE NE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254553600 | ||||||||
| FaxNumber: | 4254553920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 10092219-1204 | UT | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081S0010X | OP61081291 | WA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2162532 | 05 | WA | MEDICAID |