Provider Demographics
NPI:1104852128
Name:KEANE, VIRGINIA A (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:A
Last Name:KEANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 W ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4545
Mailing Address - Country:US
Mailing Address - Phone:410-578-8600
Mailing Address - Fax:410-578-0566
Practice Address - Street 1:1708 W ROGERS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4545
Practice Address - Country:US
Practice Address - Phone:410-578-8600
Practice Address - Fax:410-578-0566
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD468531800Medicaid
MD468531800Medicaid
B70748Medicare UPIN