Provider Demographics
NPI:1689084626
Name:KEANE, KYLE (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KEANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 SILLS RD BLDG 18
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4808
Mailing Address - Country:US
Mailing Address - Phone:631-475-1224
Mailing Address - Fax:631-475-1588
Practice Address - Street 1:285 SILLS RD BLDG 18
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-475-1224
Practice Address - Fax:631-475-1588
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281433207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program