Provider Demographics
NPI:1619997095
Name:KECK, VIRGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:
Last Name:KECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:68 S. SERVICE RD.
Mailing Address - Street 2:STE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3351
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:380 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5615
Practice Address - Country:US
Practice Address - Phone:212-975-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029346207L00000X
NY1644161207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03973306Medicaid
NYA400107492Medicare PIN