Provider Demographics
NPI:1972571958
Name:KEEN, STACEY J (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:KEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9708 OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6334
Mailing Address - Country:US
Mailing Address - Phone:410-740-2866
Mailing Address - Fax:
Practice Address - Street 1:7253 AMBASSADOR RD.
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2714
Practice Address - Country:US
Practice Address - Phone:443-436-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD324502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD546871000Medicaid
MDC57637Medicare UPIN
MD546871000Medicaid
300106696Medicare PIN
300097458Medicare PIN