Healthcare Provider Details

I. General information

NPI: 1699828566
Provider Name (Legal Business Name): KEITH MEDEIROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 UNION ST
MARLBOROUGH MA
01752-1228
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-624-9687
  • Fax: 508-624-9689
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number240000
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number240000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: