Provider Demographics
NPI:1083604573
Name:KECK, DANIEL BRUCE JR (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRUCE
Last Name:KECK
Suffix:JR
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6101
Mailing Address - Fax:859-258-4411
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-6101
Practice Address - Fax:859-258-4411
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36005207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00469361OtherRR MEDICAE PIN
KY64090475Medicaid
KY4000501OtherMEDICARE LAB GROUP#
KY37903705OtherMEDICAID LAB GROUP#
KY37903705OtherMEDICAID LAB GROUP#
KY64090475Medicaid
KY0092726Medicare PIN