1386713527 NPI number — GREGORY MARTIN KEANE D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386713527 NPI number — GREGORY MARTIN KEANE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEANE
Provider First Name:
GREGORY
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1386713527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 641130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68164-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-717-4390
Provider Business Mailing Address Fax Number:
402-717-4280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1309 HARLAN DR
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68005-6604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-291-6789
Provider Business Practice Location Address Fax Number:
402-291-8806
Provider Enumeration Date:
11/06/2006

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: 2084P0800X , with the licence number:  486 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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