Provider Demographics
NPI:1790276533
Name:KEANE, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KEANE
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 1:1288 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5245
Mailing Address - Country:US
Mailing Address - Phone:712-328-8800
Mailing Address - Fax:712-328-8467
Practice Address - Street 1:1288 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5245
Practice Address - Country:US
Practice Address - Phone:712-328-8800
Practice Address - Fax:712-328-8467
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-06052207Q00000X
CODR.0063452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine