Provider Demographics
NPI:1669489472
Name:KEOGH, BART PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:PATRICK
Last Name:KEOGH
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 1:19020 33RD AVE W
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4746
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4746
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1374
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000400842085N0700X, 2085R0202X
AKS-79762085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA218043OtherLNI PROVIDER ID
WA218046OtherLNI PROVIDER ID
WA218040OtherLNI PROVIDER ID
AK1007471Medicaid
WA8288359Medicaid
WAG8864394Medicare PIN
WA218046OtherLNI PROVIDER ID
WA218040OtherLNI PROVIDER ID
WA8288359Medicaid
WAG8864283Medicare PIN
WAG8881552Medicare PIN