1164482303 NPI number — DR. KEITH DAVID CLANCY M.D.

Table of content: TONY E JONES (NPI 1285908434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164482303 NPI number — DR. KEITH DAVID CLANCY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLANCY
Provider First Name:
KEITH
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164482303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6920 POINTE INVERNESS WAY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-7934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-479-3514
Provider Business Mailing Address Fax Number:
260-479-3520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 W JEFFERSON BLVD STE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-458-3610
Provider Business Practice Location Address Fax Number:
260-458-3611
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD067578-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 036.090092 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 35.123491 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 01079569A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: MD067578-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: 35.123491 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: 036.090092 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: MD067578-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: 35.123491 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: 01079569A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001757641 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117558 . This is a "UNISON-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 562564 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 039983 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20006031 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7731206 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01122002 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 491516 . This is a "MAMSI-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 610201 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1506063 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 56845 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0342984000 . This is a "AMERIHEALTH 65 PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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