Provider Demographics
NPI:1629410725
Name:KEAVENEY, THOMAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:KEAVENEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1322 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2199
Mailing Address - Country:US
Mailing Address - Phone:517-364-3900
Mailing Address - Fax:517-364-3514
Practice Address - Street 1:1322 E MICHIGAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2199
Practice Address - Country:US
Practice Address - Phone:517-364-3900
Practice Address - Fax:517-364-3514
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301060467208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101204501Medicare UPIN