Provider Demographics
NPI:1164482303
Name:CLANCY, KEITH DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DAVID
Last Name:CLANCY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 306
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-458-3610
Practice Address - Fax:260-458-3611
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067578-L208600000X, 2086S0102X, 2086S0127X
IL036.090092208600000X, 2086S0127X
OH35.123491208600000X, 2086S0102X, 2086S0127X
IN01079569A208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001757641Medicaid
PA117558OtherUNISON-WMG
PA562564OtherHIGHMARK BLUE SHIELD
PA039983OtherJOHNS HOPKINS
PA20006031OtherAMERIHEALTH MERCY-WMG
PA7731206OtherAETNA
PA01122002OtherCAPITAL BLUE CROSS-WMG
PA491516OtherMAMSI-WMG
MD610201OtherCAREFIRST MD BCBS
PA1506063OtherGATEWAY-WMG
PA56845OtherGEISINGER
PA0342984000OtherAMERIHEALTH 65 PA
PA117558OtherUNISON-WMG
PA56845OtherGEISINGER
MD610201OtherCAREFIRST MD BCBS
PA0342984000OtherAMERIHEALTH 65 PA