Provider Demographics
NPI:1558346858
Name:KEADLE, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KEADLE
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:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25712-0910
Mailing Address - Country:US
Mailing Address - Phone:304-522-1550
Mailing Address - Fax:304-522-1073
Practice Address - Street 1:5221 US ROUTE 60 E
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2022
Practice Address - Country:US
Practice Address - Phone:304-522-1550
Practice Address - Fax:304-522-0704
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV208282085R0202X
KYTP1552085R0202X
OH350865532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50007261OtherPASSPORT
7738308OtherAETNA
WVP00255847OtherRR MEDICARE (WV)
OH2575459Medicaid
KY6410045600Medicaid
WV55049337600OtherWORKMANS COMP
001718787OtherMTN STATE BCBS
OH000000196626OtherUNISON
WV3810002472Medicaid
7738308OtherAETNA
OH4168681Medicare PIN
KY50007261OtherPASSPORT
H50800Medicare UPIN