Basic Information
| Provider Information | |||||||||
| NPI: | 1750646295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRATULICH | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 SOUTH GIBSON ST. | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157482121 | ||||||||
| FaxNumber: | 7157487590 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 SOUTH GIBSON ST. | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157482121 | ||||||||
| FaxNumber: | 7157487590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 04/12/2016 | ||||||||
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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 | 207Q00000X | 64443-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.