Provider Demographics
NPI:1225090889
Name:CLANCE, KEITH MONTGOMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MONTGOMERY
Last Name:CLANCE
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 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:336-547-1828
Practice Address - Street 1:520 N ELAM AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1127
Practice Address - Country:US
Practice Address - Phone:336-547-1801
Practice Address - Fax:336-547-1828
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35110207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22503OtherBCBS NC PROVIDER NUMBER
NC67906OtherMEDCOST PROVIDER NUMBER
NC8922503Medicaid
NC1880OtherPARTNERS MEDICARE PROV #
NC4230049OtherAETNA PROVIDER NUMBER
NC2169594DMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NC4230049OtherAETNA PROVIDER NUMBER