Provider Demographics
NPI:1104446210
Name:KEETH, CODY BRENNAN
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:BRENNAN
Last Name:KEETH
Suffix:
Gender:
Credentials:
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 64226
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4226
Mailing Address - Country:US
Mailing Address - Phone:667-214-1734
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:667-214-1734
Practice Address - Fax:410-706-6976
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR254126363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care