Provider Demographics
NPI:1104002401
Name:KEANE, ELAINE MARY (OTRL)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:MARY
Last Name:KEANE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N ALLEGANY STREET
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21531
Mailing Address - Country:US
Mailing Address - Phone:301-722-5420
Mailing Address - Fax:
Practice Address - Street 1:ONE BAKER PLACE
Practice Address - Street 2:MINERAL COUNTY BOARD OF EDUCATION
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726
Practice Address - Country:US
Practice Address - Phone:304-788-4200
Practice Address - Fax:304-788-6461
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11502083X0100X
MD020182083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001121Medicaid