Basic Information
| Provider Information | |||||||||
| NPI: | 1679719645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEENAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PT,DPT,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 412969 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022412066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 ARDMORE AVE UNIT A | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190031339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844988299 | ||||||||
| FaxNumber: | 4844942938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2008 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 070802068 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PT024089 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.