Provider Demographics
NPI:1982149787
Name:KEANE, MICHAEL ROBERT I (LAC, BPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:KEANE
Suffix:I
Gender:M
Credentials:LAC, BPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 STANCHION DR
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-8318
Mailing Address - Country:US
Mailing Address - Phone:570-234-6216
Mailing Address - Fax:
Practice Address - Street 1:8151 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2902
Practice Address - Country:US
Practice Address - Phone:215-487-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001190171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist