Healthcare Provider Details

I. General information

NPI: 1972508968
Provider Name (Legal Business Name): KEENAN C. WANAMAKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7085 SYDNEY CURV
MONTGOMERY AL
36117-3509
US

IV. Provider business mailing address

7085 SYDNEY CURV
MONTGOMERY AL
36117-3509
US

V. Phone/Fax

Practice location:
  • Phone: 334-246-4774
  • Fax: 334-246-2450
Mailing address:
  • Phone: 334-246-4774
  • Fax: 334-246-2450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3721
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDO-900
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number3721
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: