Provider Demographics
NPI:1356962955
Name:KILLEEN, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KILLEEN
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 1:3931 INLET LOOP
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-3087
Mailing Address - Country:US
Mailing Address - Phone:502-644-0769
Mailing Address - Fax:
Practice Address - Street 1:3931 INLET LOOP
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-3087
Practice Address - Country:US
Practice Address - Phone:502-644-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN69106208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program