Provider Demographics
NPI:1053448811
Name:TOLAN, KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:TOLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:132 MILL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1978
Mailing Address - Country:US
Mailing Address - Phone:570-284-4747
Mailing Address - Fax:570-284-4748
Practice Address - Street 1:132 MILL ST
Practice Address - Street 2:SUITE B
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1978
Practice Address - Country:US
Practice Address - Phone:570-284-4747
Practice Address - Fax:570-284-4748
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058108L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA021997Medicare PIN
G84058Medicare UPIN