Basic Information
| Provider Information | |||||||||
| NPI: | 1265410716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARKINS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1275 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451338273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373936100 | ||||||||
| FaxNumber: | 9376194150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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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 | 207P00000X | 35061943 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000552748 | 01 | OH | ANTHEM BCBS | OTHER | 000000552749 | 01 | OH | ANTHEM BCBS PIKE | OTHER | 0865925 | 05 | OH | MEDICAID |