Provider Demographics
NPI:1083757884
Name:KEENER, STEPHEN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
Last Name:KEENER
Suffix:
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 1:4617 COLONY RD APT I
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4984
Mailing Address - Country:US
Mailing Address - Phone:704-551-0715
Mailing Address - Fax:704-336-4709
Practice Address - Street 1:249 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:704-336-4705
Practice Address - Fax:704-336-4709
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28053207Q00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2172006Medicare ID - Type Unspecified
NCB91644Medicare UPIN