1962413401 NPI number — EILEEN F KEANE PNP

Table of content: EILEEN F KEANE PNP (NPI 1962413401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962413401 NPI number — EILEEN F KEANE PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEANE
Provider First Name:
EILEEN
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

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:
1962413401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
374 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06513-3733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-777-7411
Provider Business Mailing Address Fax Number:
203-777-8506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
374 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06513-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-777-7411
Provider Business Practice Location Address Fax Number:
203-777-8506
Provider Enumeration Date:
08/10/2006

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: 163WP0200X , with the licence number:  006169 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 6169 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP9903 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y10141 . This is a "BCBS-GROUP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1300709 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56780 . This is a "FALLON SELECT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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