Provider Demographics
NPI:1962509323
Name:KEOGH, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5698
Mailing Address - Fax:
Practice Address - Street 1:975 KIRMAN AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-0993
Practice Address - Country:US
Practice Address - Phone:888-838-6256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500969174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948151Medicaid
NC8948151Medicaid
NC2215437CMedicare ID - Type Unspecified