Provider Demographics
NPI:1265492847
Name:KEANE, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KEANE
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 1:91 STILES RD
Mailing Address - Street 2:ATTN: SHARON SILVA
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-5804
Mailing Address - Country:US
Mailing Address - Phone:603-890-4404
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-9793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35177207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJK03672Medicaid
MA2025892Medicaid
MA99342101OtherNETWORK HEALTH
MA99342101OtherNETWORK HEALTH
MAM08337Medicare ID - Type UnspecifiedPROVIDER NUMBER