Basic Information
| Provider Information | |||||||||
| NPI: | 1780888990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEANE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 HENRY CLAY AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701185819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042691033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1430 TULANE AVE | ||||||||
| Address2: | SL-37 DEPT OF PEDIATRICS | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049885458 | ||||||||
| FaxNumber: | 5049886808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD.200119 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1061310 | 05 | LA | MEDICAID |