Provider Demographics
NPI:1114314937
Name:KEOGH, SHANE (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KEOGH
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-763-6674
Mailing Address - Fax:607-798-1629
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6674
Practice Address - Fax:607-798-1629
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00912172085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program