Provider Demographics
NPI:1255824702
Name:KEANE, ELYSE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:MARIE
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 1:5 JERRY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6734
Mailing Address - Country:US
Mailing Address - Phone:443-840-0262
Mailing Address - Fax:
Practice Address - Street 1:165 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:843-792-8792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL52508208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics