Provider Demographics
NPI:1679575492
Name:LURIE, KEITH G (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:G
Last Name:LURIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35059207RC0000X, 207RC0001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1009220OtherPREFERRED ONE
768237OtherARAZ GROUP AMERICAS PPO
179582100OtherMEDICAL ASSISTANCE
HP22045OtherHEALTH PARTNERS
77D97LUOtherBLUE CROSS BLUE SHIELD
100317OtherU CARE
MN179582100Medicaid
2500171OtherMEDICA HEALTH PLANS
179582100OtherMEDICAL ASSISTANCE
MN179582100Medicaid