Basic Information
Provider Information | |||||||||
NPI: | 1801056833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEWBROUGH | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 KINGSLEY LN | ||||||||
Address2: | STE 305 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235054614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578895942 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 KINGSLEY LN | ||||||||
Address2: | STE 305 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235054614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578895942 | ||||||||
FaxNumber: | 7578895450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2008 | ||||||||
LastUpdateDate: | 07/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01066433A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11013608A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101251332 | VA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 201024020 | 05 | IN |   | MEDICAID | P02045870 | 01 | IN | RAILROAD MEDICARE | OTHER |