Provider Demographics
NPI:1235755810
Name:KEANE, CHARLES ANTHONY (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:KEANE
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:KEANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:CMED 1632 STONE ST.
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 COOPER AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5383
Practice Address - Country:US
Practice Address - Phone:989-583-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program