Provider Demographics
NPI:1760566517
Name:SWENSEN, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:SWENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1783 ROUTE 9
Practice Address - Street 2:SUITE 105
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-2409
Practice Address - Country:US
Practice Address - Phone:518-373-2042
Practice Address - Fax:518-383-1293
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004764225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9593Medicare PIN
NYP01187Medicare UPIN