Healthcare Provider Details

I. General information

NPI: 1063699163
Provider Name (Legal Business Name): BRIAN WILLIAM KEENAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LACEY ST EMERGENCY DEPARTMENT
CAPE GIRARDEAU MO
63701-5230
US

IV. Provider business mailing address

1701 LACEY ST EMERGENCY DEPARTMENT
CAPE GIRARDEAU MO
63701-5230
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-6549
  • Fax: 573-651-5848
Mailing address:
  • Phone: 573-331-6549
  • Fax: 573-651-5848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007024787
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number294252
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2013-01907
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2014037017
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: