Provider Demographics
NPI:1760430102
Name:KEENAN, MICHAEL EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:KEENAN
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 1:1776 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-1160
Mailing Address - Country:US
Mailing Address - Phone:860-742-0807
Mailing Address - Fax:860-742-8702
Practice Address - Street 1:1776 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-1160
Practice Address - Country:US
Practice Address - Phone:860-742-0807
Practice Address - Fax:860-742-8702
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001266394Medicaid
CTB83951Medicare UPIN
CT001266394Medicaid