Healthcare Provider Details

I. General information

NPI: 1528068954
Provider Name (Legal Business Name): MARSHALL J KEILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 OCEAN AVE SUITE A8
BROOKLYN NY
11230-7393
US

IV. Provider business mailing address

2044 OCEAN AVE SUITE A8
BROOKLYN NY
11230-7393
US

V. Phone/Fax

Practice location:
  • Phone: 718-759-6065
  • Fax: 347-587-3919
Mailing address:
  • Phone: 718-759-6065
  • Fax: 347-587-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number134726
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: